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Background There is growing evidence of vaccine delays or refusals due to a lack of trust in the importance, safety, or effectiveness of vaccines, alongside persisting access issues. Although immunisation coverage is reported administratively across the world, no similarly robust monitoring system exists for vaccine confidence. In this study, vaccine confidence was mapped across 149 countries between 2015 and 2019.Methods In this large-scale retrospective data-driven analysis, we examined global trends in vaccine confidence using data from 290 surveys done between September, 2015, and December, 2019, across 149 countries, and including 284 381 individuals. We used a Bayesian multinomial logit Gaussian process model to produce estimates of public perceptions towards the safety, importance, and effectiveness of vaccines. Associations between vaccine uptake and a large range of putative drivers of uptake, including vaccine confidence, socioeconomic status, and sources of trust, were determined using univariate Bayesian logistic regressions. Gibbs sampling was used for Bayesian model inference, with 95% Bayesian highest posterior density intervals used to capture uncertainty.Findings Between November, 2015, and December, 2019, we estimate that confidence in the importance, safety, and effectiveness of vaccines fell in Afghanistan, Indonesia, Pakistan, the Philippines, and South Korea. We found significant increases in respondents strongly disagreeing that vaccines are safe between 2015 and 2019 in six countries: Afghanistan, Azerbaijan, Indonesia, Nigeria, Pakistan, and Serbia. We find signs that confidence has improved between 2018 and 2019 in some EU member states, including Finland, France, Ireland, and Italy, with recent losses detected in Poland. Confidence in the importance of vaccines (rather than in their safety or effectiveness) had the strongest univariate association with vaccine uptake compared with other determinants considered. When a link was found between individuals' religious beliefs and uptake, findings indicated that minority religious groups tended to have lower probabilities of uptake.Interpretation To our knowledge, this is the largest study of global vaccine confidence to date, allowing for crosscountry comparisons and changes over time. Our findings highlight the importance of regular monitoring to detect emerging trends to prompt interventions to build and sustain vaccine confidence.Funding European Commission, Wellcome, and Engineering and Physical Sciences Research Council.

Highlights 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.

While most people vaccinate according to the recommended schedule, this success is challenged by individuals and groups who delay or refuse vaccines. The aim of this article is to review studies on vaccine hesitancy among healthcare providers (HCPs), and the influences of their own vaccine confidence and vaccination behaviour on their vaccination recommendations to others. The search strategy was developed in Medline and then adapted across several multidisciplinary mainstream databases including Embase Classic & Embase, and PschInfo. All foreign language articles were included if the abstract was available in English. A total of 185 articles were included in the literature review. 66% studied the vaccine hesitancy among HCPs, 17% analysed concerns, attitudes and/or behaviour of HCPs towards vaccinating others, and 9% were about evaluating intervention(s). Overall, knowledge about particular vaccines, their efficacy and safety, helped to build HCPs own confidence in vaccines and their willingness to recommend vaccines to others. The importance of societal endorsement and support from colleagues was also reported. In the face of emerging vaccine hesitancy, HCPs still remain the most trusted advisor and influencer of vaccination decisions. The capacity and confidence of HCPs, though, are stretched as they are faced with time constraints, increased workload and limited resources, and often have inadequate information or training support to address parents' questions. Overall, HCPs need more support to manage the quickly evolving vaccine environment as well as changing public, especially those who are reluctant or refuse vaccination. Some recommended strategies included strengthening trust between HCPs, health authorities and policymakers, through more shared involvement in the establishment of vaccine recommendations.

Vaccine acceptance depends on public trust and confidence in the safety and efficacy of vaccines and immunization, the health system, healthcare professionals and the wider vaccine research community. This systematic review analyses the current breadth and depth of vaccine research literature that explicitly refers to the concept of trust within their stated aims or research questions. After duplicates were removed, 19,643 articles were screened by title and abstract. Of these 2,779 were screened by full text, 35 of which were included in the final analysis. These studies examined a range of trust relationships as they pertain to vaccination, including trust in healthcare professionals, the health system, the government, and friends and family members. Three studies examined generalized trust. Findings indicated that trust is often referred to implicitly (19/35), rather than explicitly examined in the context of a formal definition or discussion of the existing literature on trust in a health context. Within the quantitative research analysed, trust was commonly measured with a single-item measure (9/25). Only two studies used validated multi-item measures of trust. Three studies examined changes in trust, either following an intervention or over the course of a pandemic. The findings of this review indicate a disconnect between the current vaccine hesitancy research and the wider health-related trust literature, a dearth in research on trust in low and middle-income settings, a need for studies on how trust levels change over time and investigations on how resilience to trust-eroding information can be built into a trustworthy health system.

Maternal vaccination has been evaluated and found to be extremely effective at preventing illness in pregnant women and new-borns; however, uptake of such programmes has been low in some areas. To analyse factors contributing to uptake of vaccines globally, a systematic review on vaccine hesitancy was carried out by The Vaccine Confidence Project in 2012. In order to further analyse factors contributing to uptake of maternal immunisation, a further search within the broader systematic review was conducted using the terms 'Pregnan*' or 'Matern*'. Forty-two articles were identified. Pregnancy-related articles were further screened to identify those focused on concerns, trust and access issues regarding maternal vaccination reported by pregnant women and healthcare workers. Thirty-five relevant articles were included which were then searched using the snowballing technique to identify additional relevant references cited in these articles. A search alert was also conducted from February to April 2015 in PubMed to ensure that no new relevant articles were missed. A total of 155 relevant articles were included. Most of the literature which was identified on hesitancy surrounding vaccination during pregnancy reports on determinants of influenza vaccine uptake in North America. Research conducted in low-income countries focused primarily on tetanus vaccine acceptance. The main barriers cited were related to vaccine safety, belief that vaccine not needed or effective, not recommended by healthcare worker, low knowledge about vaacines, access issues, cost, conflicting advice. From the point of view of healthcare workers, barriers included inadequate training, inadequate reimbursement and increased workload. Twenty-seven out of 46 (59%) articles mentioning ethnicity reported lower rates of coverage among ethnic minorities. Barriers to vaccination in pregnancy are complex and vary depending on context and population. There are wide gaps in knowledge regarding the attitudes of healthcare workers and how ethnicity and gender dynamics influence a pregnant woman's decision to vaccinate.

Background The most important factor influencing maternal vaccination uptake is healthcare professional (HCP) recommendation. However, where data are available, one-third of pregnant women remain unvaccinated despite receiving a recommendation. Therefore, it is essential to understand the significance of other factors and distinguish between vaccines administered routinely and during outbreaks. This is the first systematic review and meta-analysis (PROSPERO: CRD 42019118299) to examine the strength of the relationships between identified factors and maternal vaccination uptake. Methods We searched MEDLINE, Embase Classic & Embase, PsycINFO, CINAHL Plus, Web of Science, IBSS, LILACS, AfricaWideInfo, IMEMR, and Global Health databases for studies reporting factors that influence maternal vaccination. We used random-effects models to calculate pooled odds ratios (OR) of being vaccinated by vaccine type. Findings We screened 17,236 articles and identified 120 studies from 30 countries for inclusion. Of these, 49 studies were eligible for meta-analysis. The odds of receiving a pertussis or influenza vaccination were ten to twelve-times higher among pregnant women who received a recommendation from HCPs. During the 2009 influenza pandemic an HCP recommendation increased the odds of antenatal H1N1 vaccine uptake six times (OR 6.76, 95% CI 3.12-14.64, I 2 = 92.00%). Believing there was potential for vaccine-induced harm had a negative influence on seasonal (OR 0.22, 95% CI 0.11-0.44 I 2 = 84.00%) and pandemic influenza vaccine uptake (OR 0.16, 95% CI 0.09-0.29, I 2 = 89.48%), reducing the odds of being

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