1. Reflection and decision-making process Role of public health Risk perception and evaluation Role of healthcare professionals MD RN Alternative med Counselling Training Religious literacy Open attitude Payment vs time spent counselling Vaccine delivery services Vaccination programs Impartiality / avoiding appearance of conflict of interest Relationship of trust Leave time for the decision to be made Continuity Relationship of trust Accurate information Empowerment Historic and socio-cultural context Link of trust Religious and cultural particularities Communications and media Social media Internet Ethics Spirituality Medical expertise Science Pharmaceutical companies Government Healthcare systems Vaccine coverage Rigorous evaluation Vaccination registers Avoid VPD epidemics Population effects Individual effects Laws / incentives? Message Statistical data Vaccine safety Consequences / gravity of VPD Different for each person May not be rational Perception changes when children or the vulnerable involved Low risk of undesirable events Very low incidence of diseases, thus poorly known Vaccine hesitancy Communication skills Medical and epidemiological knowledge Hesitant professionals Educating Patients/parents Recommend vaccination Continuum of hesitancy refusal acceptance WORKSHOP ON THE CULTURAL AND RELIGIOUS ROOTS OF VACCINE HESITANCY: Context Vaccine hesitancy causes a decrease in vaccine coverage and increases the risk of outbreaks and epidemics of vaccine-preventable diseases. Diseases believed to be controlled, such as measles, are reappearing today. A workshop was held on December 5, 2011, in Longueuil, Quebec, to consider this phenomenon of vaccine hesitancy. Some forty experts from various fields and from several Canadian provinces met to share their views (Figure 1). The workshop was structured as follows: short presentations were made on various themes related to vaccine hesitancy, for the purpose of encouraging a long period of discussion and debate among participants. Purpose To report workshop participants’ opinions. During the workshop, the debates were recorded, and a short self-administered questionnaire was filled out by participants, whose opinions on factors contributing to vaccine hesitancy were solicited by means of several open questions. Minutes of the discussions were then written up and the content validated using the recordings. The questionnaire responses were compiled on Excel. A content analysis was carried out on all the material. Method The questionnaire response rate was 59% (22/37). For four major subjects—the role of healthcare professionals, the role of public health, the population’s perception and evaluation of risk, and the reflection and decision-making process (Figure 2), seven categories of factors were identified: communications and public exposure to vaccine information, the public’s level of knowledge about immunization, risk evaluation and decision-making, trust/mistrust, personal factors, the socio- cultural context, and the vaccination context (Table 1). Results Emotional, cultural, social and spiritual factors seem to influence the vaccination decision as much as cognitive factors. Healthcare professionals and public health bodies play a unique role with regard to vaccine-hesitant people. A dialogue must be established regarding vaccination decisions. To help professionals assume an empathetic, open- minded support role toward the hesitant population, the publication of a book on the subject is planned that will bring together the learning and ideas shared during this workshop. Conclusion CategoryFactors mentioned Communication and public’s exposure to information (13/22) Information communicated to the public (e.g. type of information, reliability, quantity, credibility) Information conveyed by health professionals (often hesitant themselves) Messages communicated by public health bodies Education offered on immunization Media, Internet, social networks Exposure to anti-vaccination messages Importance placed on anecdotal data or controversies surrounding vaccines Public’s level of knowledge about immunization (11/22) Access to enough information on vaccination Knowledge / lack of knowledge of risks of vaccine-preventable diseases Difficulty observing directly the effects of vaccine-preventable diseases Knowledge / lack of knowledge of vaccine efficacy Knowledge / lack of knowledge of scientific bases of vaccination Risk evaluation and decision-making process (10/22) Risk and benefit assessment process Enlightened decision-making Fear of side effects of vaccines Fear of undesirable adverse events of immunization Importance placed on anecdotal events Trust/mistrust (10/22) Mistrust (general) Trust/mistrust in science, government, medicine, conventional healthcare, the health system, public health Mistrust of the big three (pharma, government and business) Personal factors: - perceptions - personal opinions - membership groups (9/22) Beliefs, values, knowledge, attitudes Ideologies Personal experiences or in one’s entourage Socio-economic status Religious or cultural membership Belief in alternative medicine Socio-cultural context (3/22) Possibility of relying on group immunity Social norms/acceptance Polarization of opinions Social values Culture Religion Historical events / population’s experience Vaccine delivery context (1/22) Increase in number of vaccines recommended on the vaccine schedule Role played by health professionals EXPLANATIONS AND IMPLICATIONS FOR CANADIAN HEALTHCARE (draft – do not disseminate) Figure 2 – Determinants of vaccine hesitancy: schema summary of discussions Hesitant mother Anthropologists Medical historian Experts in ethics, psychology and risk perception Expert in religious studies and multiculturalism Humanities and social sciences Nurses Family doctors Pediatricians Internist Microbiologists Chiropractor Biomedical sciences Family doctors Nurses Medical specialists Epidemiologists Communication agents Public health Figure 1 – Workshop participants Table 1 – Factors in vaccine hesitancy as mentioned by participants on the questionnaire (x mentions / 22 respondents) Caroline Laberge; Maryse Guay; Paule Clément; Paul Bramadat; Réal Roy; Julie Bettinger