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• Most parents stated they would likely accept a COVID-19 vaccine for themselves and their children. • Ethnicity and household income were predictors of COVID-19 vaccine refusal. • The main motivation for vaccine acceptance was for self-protection against COVID-19. • Foremost concerns were around the safety and efficacy of a 'rushed' new vaccine. The availability of a COVID-19 vaccine has been heralded as key to controlling the COVID-19 pandemic. COVID-19 vaccination programme success will rely on public willingness to be vaccinated. We used a multi-methods approach - involving an online cross-sectional survey and semi-structured interviews - to investigate parents' and guardians' views on the acceptability of a future COVID-19 vaccine. 1252 parents and guardians (aged 16 + years) who reported living in England with a child aged 18 months or under completed the survey. Nineteen survey participants were interviewed. Most survey participants reported they would likely accept a COVID-19 vaccine for themselves (Definitely 55.8%; Unsure but leaning towards yes 34.3%) and their child/children (Definitely 48.2%; Unsure but leaning towards yes 40.9%). Less than 4% of survey participants reported that they would definitely not accept a COVID-19 vaccine. Survey participants were more likely to accept a COVID-19 vaccine for themselves than their child/children. Participants that self-reported as Black, Asian, Chinese, Mixed or Other ethnicity were almost 3 times more likely to reject a COVID-19 vaccine for themselves and their children than White British, White Irish and White Other participants. Survey participants from lower-income households were also more likely to reject a COVID-19 vaccine. In open-text survey responses and interviews, self-protection from COVID-19 was reported as the main reason for vaccine acceptance. Common concerns identified in open-text responses and interviews were around COVID-19 vaccine safety and effectiveness, mostly prompted by the newness and rapid development of the vaccine. Information on how COVID-19 vaccines are developed and tested, including their safety and efficacy, must be communicated clearly to the public. To prevent inequalities in uptake, it is crucial to understand and address factors that may affect COVID-19 vaccine acceptability in ethnic minority and lower-income groups who are disproportionately affected by COVID-19. [ABSTRACT FROM AUTHOR]

• The opt-out policy was difficult to implement and not well received by NHS staff. • The purpose of the policy was poorly understood, and NHS staff did not know how data on decliners was being used. • NHS staff were concerned that the the policy could be used to 'name and shame' decliners. • Redeployment of unvaccinated NHS staff was found impractical due to staffing levels. • Workforce engagement in designing flu vaccination approaches is key to their success. In 2018/19, English NHS trusts (NHSTs) implemented an 'opt-out' policy for seasonal flu vaccination in frontline healthcare workers (HCWs). HCWs declining the vaccination were asked to sign an opt-out form and provide a reason for their decision. In addition, HCWs working in higher risk hospital environments (e.g. oncology) were asked to inform their manager about their declination decision. The policy aimed to provide greater insight into reasons for vaccination decline and information from HCWs in higher risk areas was intended for use in considering HCW redeployment. This study investigated the feasibility, acceptability, and perceived value of the policy during the 2018/19 flu vaccination season. We conducted semi-structured interviews across 9 NHSTs in England with different levels of HCW flu vaccination uptake in 2017/18. We interviewed 30 vaccination programme implementers and 27 managers. The purpose of the policy was poorly understood, and interviewees did not know how data on decliners was being used. Most NHSTs tried to collect the personal details of decliners and, in some instances, these were recorded in Electronic Staff Records and reported to line-managers for action. This created strain on employer-employee relationships, leading to decliners refusing to complete opt-out forms and some vaccinators not implementing the policy. None of the NHSTs had a redeployment policy for decliners, arguing that this was impractical due to strain on staffing levels. A flu-vaccination opt-out approach for HCWs did not appear acceptable in our sampled NHSTs, due to a lack of clear messaging about its purpose and complicated implementation. To promote an opt-out approach effectively, there needs to be clear communication of its purpose, which should be to explore reasons for decline rather than identify and 'push' decliners to vaccinate, so as not to damage staff relationships. NHSTs should involve their workforce in developing flu vaccination approaches. [ABSTRACT FROM AUTHOR]

• Wide variation in uptake of flu vaccine persists in English NHS hospitals. • Many factors of high uptake are linked to leadership and organisational culture. • Embedding the flu programme in well-being policy helps acceptability and adherence. • A supportive culture is likely to achieve higher uptake than a coercive one. • Middle managers' facilitating role in delivering the programme is key to uptake. Health care workers are a priority group for seasonal influenza vaccination, which is recommended by the World Health Organisation. There is a wide variation in uptake between and within countries. England has achieved 69.5% of health care workers vaccinated overall in 2017/18 across NHS acute and community health care settings, but it varies between Trusts from 50% to over 92.3%. While attitudinal factors have been well researched, there is limited evidence on organisational factors associated with high uptake. In England, most NHS Trusts are now implementing a similar range of interventions as part of their flu programme, and it remains unclear why performance remains so variable. This qualitative study is the first to explore reasons for this variation and provide recommendations for lower performing Trusts on how to improve. Fifty-seven interviews of managers and vaccinators were conducted in nine hospitals with flu vaccination uptake ranging from just over 55% to above 90%. Our study found that while Trusts deployed a wide range of both demand generating and supply interventions to increase uptake, there were marked differences in the organisational and delivery models utilised. Our study suggests that organisational culture was possibly the most important ingredient when trying to differentiate between high and low performing Trusts. We found that a positive culture aimed at fostering continuous improvement and favouring non-coercion on balance yielded more adherence from staff. Where influenza vaccination was embedded in the organisation wellbeing strategy, rather than executed as a siloed seasonal programme, this tended to foster good performance. Improving performance of influenza vaccination in health care workers will involve not only deploying the right interventions, and following "best practices". It will require the adaptation of flu progamme delivery strategies to the organisation context, and embedding vaccination into the organisational culture, thus supporting the normalisation of yearly vaccination. [ABSTRACT FROM AUTHOR]

The early introduction group participants of the Enquiring About Tolerance study were asked to undertake a proscriptive regimen of early introduction and sustained consumption of 6 allergenic foods. It was envisaged that this might be challenging, and early introduction group families were presented with an open-text question to express any problems they were experiencing with the regimen in recurring online questionnaires. We sought to analyze these open-text questionnaire responses with the aim of identifying challenges associated with the introduction and regular consumption of allergenic foods. Three combinations of interim questionnaire responses were selected for analysis, representing the early period (4, 5, and 6 months), middle period (8 and 12 months), and late period (24 and 36 months) of participation in the Enquiring About Tolerance study. Responses were assigned a code to describe their content and subsequently grouped into themes to portray key messages. A thematic content analysis allowed for conversion of qualitative codes into quantitative summaries. Three main challenges to allergenic food consumption were identified. First, some children refused the allergenic food, causing a sense of defeat among caregivers. Second, caregivers were concerned that allergenic foods might be causing a reaction, triggering a need for reassurance. Third, practical problems associated with the regimen compromised caregivers' capacity to persist. Understanding the challenges experienced with allergenic food introduction and sustained consumption is the necessary precursor to developing specific communication and support strategies that could be used by caregivers, practitioners, policymakers, and key stakeholders to address these problems. [ABSTRACT FROM AUTHOR]

• Access to pregnancy vaccines in the United Kingdom was disrupted by the COVID-19 pandemic. • UK pregnant women reported difficulties & feeling less safe accessing vaccine appointments for themselves & for their babies during COVID-19. • Ethnic minority women were more likely to report difficulties accessing vaccine appointments during COVID-19 therefore services must ensure equitable access during the ongoing pandemic. COVID-19 changed access to healthcare, including vaccinations, in the United Kingdom (UK). This study explored UK women's experiences of accessing pertussis vaccination during pregnancy and infant vaccinations during COVID-19. An online cross-sectional survey was completed, between 3rd August-11th October 2020, by 1404 women aged 16+ years who were pregnant at some point after the first UK lockdown from March 23rd, 2020. Ten follow-up semi-structured interviews were conducted. Most women surveyed were pregnant (65.7%) and a third postnatal (34.3%). Almost all women (95.6%) were aware that pertussis vaccination is recommended in pregnancy. Most pregnant (72.1%) and postnatal women (84.0%) had received pertussis vaccination; however, access issues were reported. Over a third (39.6%) of women had a pregnancy vaccination appointment changed. COVID-19 made it physically difficult to access pregnancy vaccinations for one fifth (21.5%) of women and physically difficult to access infant vaccinations for almost half of women (45.8%). Nearly half of women (45.2%) reported feeling less safe attending pregnancy vaccinations and over three quarters (76.3%) less safe attending infant vaccinations due to COVID-19. The majority (94.2%) felt it was important to get their baby vaccinated during COVID-19. Pregnant women from ethnic-minorities and lower-income households were less likely to have been vaccinated. Minority-ethnicity women were more likely to report access problems and feeling less safe attending vaccinations for both themselves and their babies. Qualitative analysis found women experienced difficulties accessing antenatal care and relied on knowledge from previous pregnancies to access vaccines in pregnancy. During the ongoing and future pandemics, healthcare services should prioritise equitable access to routine vaccinations, including tailoring services for ethnic-minority families who experience greater barriers to vaccination. [ABSTRACT FROM AUTHOR]

Introduction Improving evidence informed decision-making in immunisation is a global health priority and many low and middle-income countries have established National Immunisation Technical Advisory Groups (NITAGs) as independent technical advisory bodies for this purpose. NITAG development and strengthening has received financial and technical support over the past decade, but relatively little evaluation. This study examined NITAGs in six low and middle-income countries (i.e. Armenia, Ghana, Indonesia, Nigeria, Senegal, Uganda), to examine functionality, quality of recommendation development, and integration with national decision-making bodies and processes. Methods A mixed-method case-series design, used semi-structured interviews, NITAG meeting observations, and document review. Data were analysed thematically. Results Five NITAGs had been legally established with terms of reference and appeared well functioning, with Ghana’s in development. All NITAGs had standard operating procedures and nomination procedures to ensure a range of expertise, generally comprising 10–15 core, 1–5 secretariat, and several ex-officio members. Aside from economics, NITAGs reported a wide range of member expertise. Newer NITAGs had particular concerns about funding. Four used formal conflict of interest procedures, although some commented that implications were not always understood. NITAGs valued local data, and limited evidence suggested NITAG presence might reinforce data production through surveillance and local research studies. All observed meetings demonstrated due process and evidence-based decision-making processes were generally followed, with a critical role played by working-group data syntheses and assessments. NITAGs were seen as well integrated with ministry of health (MoH) decision-making and MoH interviewees were positive about NITAG contributions, indicating NITAGs had an important role. Collaboration with other bodies was more limited, but mitigated by NITAG members’ cross-membership in other bodies. Conclusions NITAGs have an important and valued role within national immunisation decision-making. However, their position remains insecure, with the need for sustainable technical and financial support. [ABSTRACT FROM AUTHOR]

Shocks effects are under-theorised in the growing literature on health system resilience. Existing work has focused on the effects of single shocks on discrete elements within the health system, typically at national level. Using qualitative system dynamics, we explored how effects of multiple shocks interacted across system levels and combined with existing vulnerabilities to produce effects on essential health services delivery, through the prism of a case study on childhood vaccination in Lebanon. Lebanon has experienced a series of shocks in recent years, including large-scale refugee arrivals from neighbouring Syria, the COVID-19 pandemic and a political-economic crisis. We developed a causal loop diagram (CLD) to explore the effects of each shock individually, and in combination. The CLD was developed and validated using qualitative data from interviews with 38 stakeholders working in Lebanon's vaccination delivery system, in roles ranging from national level policy to facility-level service delivery, conducted between February 2020 and January 2022. We found that each of the shocks had different effects on service demand- and supply-side dynamics. These effects cascaded from national through to local levels. Both Syrian refugee movement and the COVID-19 pandemic primarily exposed vulnerabilities in service demand, mainly through slowly emerging knock-on effects on vaccination uptake behaviour among host communities, and fear of contracting infection in crowded health facilities respectively. The economic crisis exposed wider system vulnerabilities, including demand for vaccination as household income collapsed, and supply-side effects such as reduced clinic time for vaccination, declining workforce retention, and reduced availability of viable vaccine doses, among others. Finally, important pathways of interaction between shocks were identified, particularly affecting the balance between demand for vaccination through publicly supported facilities and private clinics. Future research should incorporate dynamic approaches to identifying within-system vulnerabilities and their potential impacts under different scenarios, as a precursor to improved resilience measurement, system preparedness, and intervention targeting. • Shocks effects are under-theorised in the health systems literature. • Sequential shocks had interacting effects on vaccination delivery in Lebanon. • These shocks also exposed both demand- and supply-side system vulnerabilities. • Stability in human resourcing and funding flows is key for system resilience. • Dynamic methods can help identify resilience-promoting measures and their effects. [ABSTRACT FROM AUTHOR]