11.M. Workshop: Vaccination hesitancy in the Western Balkans and inclusive governance

Abstract   Vaccine hesitancy has been identified as one of the crucial contributors to the global decline in vaccination coverage for several well-established vaccines in previous decades and is listed by the World Health Organization as one of the top ten threats to global health. In developing countries, the leading reasons for under-vaccination appear to be the lack of access, low education and socio-economic status. In developed countries psychological, social, and contextual factors are defined as main drivers of vaccine hesitancy. With the COVID-19 pandemic the threat of vaccine hesitancy has become more evident and is now in the focus of strategies and efforts to improve and strengthen the interventions to combat vaccine hesitancy and increase vaccination coverage. Despite the availability of multiple effective vaccines against COVID-19, only 40% of population of Wester Balkans in average has been completely vaccinated (with a complete initial protocol), which is far below the world average (56%). Vaccine hesitancy largely jeopardizes the achievement of heard immunity, postponing the end of the pandemic. To explore reasons of vaccine hesitancy, the cross-sectional and quasi-experimental studies were performed from July to September 2021 in five countries of the Western Balkans: Albania, Bosnia-Herzegovina, Montenegro, North Macedonia, and Serbia. The results will be presented and discussed from a policy perspective. The first presentation will introduce to the actual debate around vaccination hesitancy; the second presentation describes the survey design and key results related to societal factors (confidence in political and health authorities, science, and pharmaceutical companies), social responsibility (personal sense of responsibility in achieving collective immunity and contagion prevention) and the credibility of information sources about COVID-19 vaccines; the third presentation will discuss components of credibility (expertise, trustworthiness, and caring/goodwill) after respondents’ exposure to messages with narratives on COVID-19 vaccine decisions. The fourth presentation is going to identify promising policy options. The objective of the workshop is to present and discuss the results of the Western Balkans study, relate them to corresponding studies in Europe and beyond, and propose effective interventions. The audience is invited to discuss the findings and the practicability of strategies to improve the acceptance of qualified information in the population, how to enhance trustworthy, how to improve vaccination rates. The discussion will focus on the following questions: a) What are the main drivers of vaccination hesitancy? b) Which messaging format is most convincing and trustworthy? c) Why is the global dimension essential? Key messages • Vaccine hesitancy is a serious threat and reason for the insufficient vaccination coverage and suboptimal herd immunity in the Western Balkans. • Vaccination policy has to enhance information trustworthy and source credibility at the national level and argue for fair resource distribution in the global dimension.


Background:
Internationally, an increasing body of scholarship has focused on the experiences of transgender individuals when accessing gender-affirming healthcare. However, the experiences of transgender individuals who belong to the foreign background population in Finland have rarely been studied. This study aims to fill the gap in research and contribute to the understanding of the experiences of acquiring gender-affirming healthcare among those, who fall into the intersections of transness and also identify of foreign origin in Finland.

Methods:
Fourteen semi-structured qualitative interviews were conducted and analyzed with reflexive thematic analysis (RTA), through the framework of intersectionality. The interviews were part of a broader sample of qualitative data, collected about the experiences of sexual and gender minorities among the foreign origin populations in Finland.

Results:
The analysis showed two main interconnected themes. Firstly, perceived barriers when accessing gender-affirming care. In this theme, the intersections of transgender identity, foreign background, class, and age affected the experiences of the individuals. Secondly, the necessity of ''performing identities:'' the intersections of class, transgender identity, and race affected those.

Conclusions:
The findings of the current study suggest that the intersectional aspects of individual identities create structural inequalities in the Finnish gender-affirmation healthcare system. To tackle these inequalities, further research is needed on the healthcare experiences of gender minorities in Finland both within and outside the scope of transgender-specific healthcare.

Key messages:
Intersectional aspects of individual identities create structural inequalities in accessing gender-affirming healthcare. Further research is needed on the healthcare experiences of gender minorities that examines health and wellbeing using an intersectional lens.
Vaccine hesitancy has been identified as one of the crucial contributors to the global decline in vaccination coverage for several well-established vaccines in previous decades and is listed by the World Health Organization as one of the top ten threats to global health. In developing countries, the leading reasons for under-vaccination appear to be the lack of access, low education and socio-economic status. In developed countries psychological, social, and contextual factors are defined as main drivers of vaccine hesitancy. With the COVID-19 pandemic the threat of vaccine hesitancy has become more evident and is now in the focus of strategies and efforts to improve and strengthen the interventions to combat vaccine hesitancy and increase vaccination coverage. Despite the availability of multiple effective vaccines against COVID-19, only 40% of population of Wester Balkans in average has been completely vaccinated (with a complete initial protocol), which is far below the world average (56%). Vaccine hesitancy largely jeopardizes the achievement of heard immunity, postponing the end of the pandemic. To explore reasons of vaccine hesitancy, the cross-sectional and quasi-experimental studies were performed from July to September 2021 in five countries of the Western Balkans: Albania, Bosnia-Herzegovina, Montenegro, North Macedonia, and Serbia. The results will be presented and discussed from a policy perspective. The first presentation will introduce to the actual debate around vaccination hesitancy; the second presentation describes the survey design and key results related to societal factors (confidence in political and health authorities, science, and pharmaceutical companies), social responsibility (personal sense of responsibility in achieving collective immunity and contagion prevention) and the credibility of information sources about COVID-19 vaccines; the third presentation will discuss components of credibility (expertise, trustworthiness, and caring/goodwill) after respondents' exposure to messages with narratives on COVID-19 vaccine decisions. The fourth presentation is going to identify promising policy options. The objective of the workshop is to present and discuss the results of the Western Balkans study, relate them to corresponding studies in Europe and beyond, and propose effective interventions. The audience is invited to discuss the findings and the practicability of strategies to improve the acceptance of qualified information in the population, how to enhance trustworthy, how to improve vaccination rates. The discussion will focus on the following questions: a) What are the main drivers of vaccination hesitancy? b) Which messaging format is most convincing and trustworthy? c) Why is the global dimension essential? Key messages: Vaccine hesitancy is a serious threat and reason for the insufficient vaccination coverage and suboptimal herd immunity in the Western Balkans.
Vaccination policy has to enhance information trustworthy and source credibility at the national level and argue for fair resource distribution in the global dimension.

Vaccine hesitancy is a relatively new concept, developed by WHO's Strategic Advisory Group of Experts (SAGE) on
Immunization in 2014 as a response to the growing awareness of the decline in global confidence in vaccination. Vaccine hesitancy is a context-specific behavioural phenomenon whose occurrence ranges between full acceptance and complete refusal of vaccines. Several studies have explored factors that influence people's decision to get vaccinated and in 2018 WHO and UNICEF conducted a joint study to explore the reasons for vaccine hesitancy. The study aimed to determine the reported rate of vaccine hesitancy across the globe and the reasons for hesitancy. In most studies three top reasons were identified. 1) vaccine safety concerns, 2) lack of knowledge and awareness of vaccine importance, and 3) religion, culture, gender and socio-economic issues regarding vaccines. Other factors contributing are negative perception of vaccine efficacy, safety, convenience, and price. Some of the consistent sociodemographic groups that were identified to be associated with increased hesitancy included: women, younger participants, and people who were less educated, had lower income, had no insurance, lived in a rural area, and self-identified as a racial/ ethnic minority. Vaccine hesitancy is associated with the global crisis of trust in science and institutions, namely lack of political trust, which can be defined as public judgment that the system and its representatives are responsive and reliable. Furthermore, distrust in one institution is related to distrust in other, indicating the unidimensional phenomenon. This kind of distrust is exemplified by the appearance of infodemic -an overabundance of information. In addition, support for conspiracy theories related to COVID-19 which correlates with the scepticism towards vaccination has significantly higher rates among Balkans' populations.

Background:
The vaccine hesitancy is a matter of global concern with inadequate global uptake postponing the moment of reaching herd immunity and bringing the COVID-19 pandemics under control. Countries in the Western Balkans struggle with vaccine hesitancy, trying to bring vaccine acceptance and ways to improve it into the focus.

Methods:
A cross-sectional study on vaccine hesitancy was conducted from July to September 2021 and included adult population from Albania, Bosnia and Herzegovina, North Macedonia, Montenegro and Serbia (1605 individuals). Convenience sampling was applied using anonymized online questionnaire (shared through social media) measuring, among others, trust in societal factors, social responsibility and, the credibility of information sources about COVID-19 vaccines.

Results:
The highest degree of trust in societal factors was found in North Macedonia (M = 3.65, SD = 1.06), followed by Montenegro (M = 3.50, SD = 1.19) and Serbia (M = 3.24, SD = 1.26). In Albania 44.7% respondents believed in reluctance of pharmaceutical companies to publish detailed research reports on the risks of adverse reactions to COVID-19 vaccines. The view that the health authorities when they encourage vaccination do so with the best intentions supported 66,3% respondents in North Macedonia and 49% in Albania and Serbia. The highest level of social responsibility (M = 4.12, SD = 1.09) was revealed in North Macedonia. Primary care physicians, health professionals in media, webpages of public health institutions, and scientific literature are the most trusted sources of information about COVID-19 in all countries.

Conclusions:
The study demonstrated moderate trust in societal factors and moderately high level of social responsibility in all countries. The health professionals enjoy the greatest trust, which implies that medical doctors, especially physicians in primary health care should have a pivotal role in promoting vaccination and educating the general public in the Western Balkans.