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Influenza is a severe, vaccine-preventable disease. Vaccination programs across Latin American countries show contrasting coverage rates, from 29% in Paraguay to 89% in Brazil. This study explores how national influenza vaccination programs in the chosen South American countries address vaccine confidence and convenience, as well as complacency toward the disease. Barriers and facilitators to influenza vaccination programs in their relation to vaccine hesitancy were observed by documentary analysis and interviews with 38 national immunization program officers in high- (Brazil and Chile) and low-performing (Paraguay, Peru, and Uruguay) countries. Influenza vaccination policies, financing, purchasing, coordination, and accessibility are considered good or acceptable. National communication strategies focus on vaccine availability during campaigns. In Chile, Paraguay, and Uruguay, anti-vaccine propaganda was mentioned as a problem. Programming and implementation face human resource shortages across most countries. Statistical information, health information systems, and nominal risk-group records are available, with limitations in Peru and Paraguay. Health promotion, supervision, monitoring, and evaluation are perceived as opportunities to address confidence and complacency. Influenza vaccination programs identify and act on most barriers and facilitators affecting influenza vaccine hesitancy via supply-side strategies which mostly address vaccine convenience. Confidence and complacency are insufficiently addressed, except for Uruguay. Programs have the opportunity to develop integral supply and demand-side approaches.

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.

Influenza vaccination has been available under Peru's national immunization program since 2008, but vaccination coverage has decreased lately. Surveys and focus groups were conducted among four risk groups (pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥65 years) to identify factors affecting influenza vaccine hesitancy in Peru. The 3Cs model (Confidence, Complacency, and Convenience) was used as a conceptual framework for the study. Most pregnant women and mothers of young children (70.0%), but less than half (46.3%) of older adults and adults with risk factors were vaccinated against influenza. Vaccine confidence and complacency were positively associated with educational level. Complacency was the most deficient of the 3Cs. Pregnant women and mothers were the most informed and least complacent among risk groups. Focus groups revealed the misconceptions behind the high level of complacency observed, including the perception of influenza risk and the role assigned to vaccination in preventing the disease. Interviews with officials identified that most strategies are directed to vaccination availability and hence to convenience, with opportunities for strategies to improve vaccination uptake and community engagement. The results highlight the importance of implementing in Peru communication strategies to increase perceptions of vaccine safety and effectiveness thus improving confidence and reducing complacency. The establishment of explicit incentives should also be considered to increase vaccination uptake, particularly to health personnel.