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Influenza vaccination coverage in countries of Latin America is low among priority risk groups, ranging from 5 to 75% among older people. This paper aims to describe and analyze the determinants of influenza vaccination hesitancy through the lens of the 3C model of confidence, complacency and convenience among middle-class, urban risk group populations in Brazil, Chile, Paraguay, Peru, Uruguay, countries in South America with contrasting vaccination coverage. Focus groups were conducted among four risk groups: pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥60 years in samples of urban residents. Adults with risk factors expressed the most detailed perceptions about confidence in the vaccine. A wide range of perceptions regarding complacency were expressed across risk groups and countries, with pregnant women and mothers showing greater concerns while convenience had a narrower and generally more positive range of perceptions. Participants from Chile and Paraguay expressed the most contrasts regarding confidence and complacency. Information and communication strategies need to be tailored for risk groups while confidence and complacency should be addressed in synergy., Competing Interests: I hereby acknowledge that our project was financially supported by Sanofi Pasteur. This does not alter our adherence to PLOS ONE policies on sharing data and materials. One of our co-authors, Elsa Sarti, is an employee of Sanofi Pasteur. All other authors have no relevant conflicts of interest to report.

Introduction: Influenza morbidity and mortality are significant in the countries of South America, yet influenza vaccination is as low as 56.7% among pregnant women, reaching 76.7% of adults with chronic diseases. This article measures the relative values for the vaccination hesitancy indicators of confidence, complacency and convenience by risk-groups in urban areas of five countries of South America with contrasting vaccination rates, analyzing their association with sociodemographic variables and self-reported immunization status., Methods: An exit survey was applied to 640 individuals per country in Brazil, Chile, Paraguay, Peru and Uruguay, distributed equally across risk groups of older adults, adults with risk factors, children ≤6 and pregnant women. Indicators were constructed for vaccine confidence, complacency and convenience. Analysis of variance and multiple logistic analysis was undertaken., Results: Adults with risk factors are somewhat more confident of the influenza vaccine yet also more complacent. Convenience is higher for mothers of minors. Children and older adults report higher levels of vaccination. The 3Cs are more different across countries than across risk groups, with values for Chile higher for confidence and those for Uruguay the lowest. Complacency is lower in Brazil and higher in Uruguay. Results suggest that confidence and complacency affect vaccination rates across risk groups and countries., Conclusions: Influenza vaccine confidence, complacency and convenience have to be bolstered to improve effective coverage across all risk groups in the urban areas of the countries studied. The role played by country contextual and national vaccination programs has to be further researched in relation to effective coverage of influenza vaccine., Competing Interests: The authors have read the journal's policy and the authors of this manuscript have the following competing interests: ES and EPR are paid employees of Sanofi Pasteur and MAGB, BRZ and MR are paid employees of Evisys Consulting. BRZ and MR participated in the research as paid, pro-tempore employees of Evisys. EGC, BEP, JA, YC, PC, AFL, LN, DRK participated as Evisys consultants. Both Sanofi Pasteur and Evisys participated in study design and manuscript review. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.