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Abstract

Introduction:

Under the mandate of supporting European immunisation cooperation and strategies, the specific aim of this work was about focusing on vaccine communication in order to raise awareness, increase confidence and strengthen the practice for vaccination in Italy.

Methods:

The four-step Plan-Do-Check-Act cycle applied through a bundle of actions: (Plan) studying national vaccination scenarios and factors underlying vaccine hesitancy by developing a reference grid; (Do) creating a web platform-based toolbox with vaccine communication tools; (Check) engaging within national stakeholders within dedicated roundtables also associated to media trainings; (Act) co-developing, or co-selecting, tools to pilot amongst identified target communities.

Results:

In 2021, we analysed evidence on vaccine hesitancy determinants in scientific (86%) and grey (14%) literature by applying contextual, individual, and vaccine-specific categories. A total of 42 out of 204 vaccine communication tools collected and evaluated in early 2022 referred to Italy. In mid-2022, participatory dialogue and engagement with national stakeholders, media included, addressed vaccine communication improvements in different target populations. In late 2022, co-creation/selection of vaccine communication tools and their piloting focused on specific vaccinations and communities, such as the school setting for Italy.

Conclusions:

To address better vaccine communication outcomes, efforts on multistakeholder collaboration, training and advocacy are needed.

Keywords

vaccination vaccine communication health professionals target communities stakeholder engagement training

Introduction

Immunisation is defined as a successful global health, development and investment story, saving millions of lives every year. Nowadays, despite vaccines are available to prevent more than 20 life-threatening diseases, far too many people around the world – including nearly 20 million infants each year – have insufficient access opportunity to vaccinate. Additionally, in some countries, progress has stalled or even reversed, although the Coronavirus disease (COVID-19) pandemic served as further occasion to highlight the power of vaccines to fight disease, save lives, and create a healthier, safer, and more prosperous future. The World Health Assembly endorsed a new global vision and strategy, the Immunization Agenda 2030 (IA2030), to address all the vaccine-related challenges over the next decade by envisioning a world where everyone, everywhere, at every age – no one left behind, in any situation or at any stage of life – fully benefits from vaccines for better health and well-being.^1-3

When we come to the national levels, strengthening and improving vaccination programme implementation necessarily require some actions such as firstly developing data collection and analysis on vaccination components, then sustaining decision-making by consolidating and constantly updating available information on agreed indicators, benchmarked targets, methods and procedures, and delivering rapid and prompt reporting with relevant data. Monitoring and Evaluation (M&E) frameworks are quite complex because they usually aggregated into pre-, peri-, and post-vaccination phases, and include elements of vaccine procurement, transport, storage, staff training, communication, coverage, adverse effects, and identification of successes and failures.⁴

Within the European Union (EU) Health Programme, under the mandate of increasing immunisation cooperation and vaccine outcomes in the EU, a specific focus was on studying existing vaccine communication tools in view of further supporting new strategies to raise awareness as well as empower and improve vaccination compliance in target population communities (eg, citizens, health professionals or other stakeholders), even with the aim to amplify visibility and role of the Coalition for Vaccination.⁵

In order to achieve this vaccine communication objective aimed at extensive vaccination confidence and equitable uptake, a bundle of actions was developed: from understanding dynamics preventing access to vaccines up to strengthening stakeholder collaboration, through training and dissemination activities. A key action point is in fact the professional training to upskill healthcare practitioners to effectively tackle increasing complexities and uncertainties experienced in primary care in matter of promoting vaccination. We developed a two-fold approach: on the one hand, enhancing vaccine strategies which are recommended both at community level and within each country and, on the other hand, contributing to increase knowledge on vaccines and vaccinations especially among health professionals by better addressing information circulation in different target groups through a multistakeholder collaboration. In alignment to this participatory approach, indeed communication and training actions were mostly emphasised to raise vaccine awareness in specific population groups, by studying mechanisms most hindering vaccine access and, conversely, potential measures and solutions to overcome the identified barriers.

In showing how processes and workflows for effective vaccine-related strategies and interventions would be supposed to be delivered, we specifically describe the Italian case that highlights to what extent vaccination policies need to be based on integrated and coordinated communication initiatives. As noted, the process as a whole has necessarily to include the real engagement of all relevant stakeholders in the field, firstly acknowledging scientific evidence on effective actions to develop and tools to use in order to improve vaccinations in the different population groups. Focusing on the Italian case, the paper shows how the interdisciplinary “journey” for improved forms of communication on vaccinations is crucial for advancing practice in achieving increased vaccine coverage that represents both a major and challenging issue within primary care settings and public community health.

Materials and Methods

As largely used in public health, we adopted the four-step W. Edwards Deming’s model, Plan-Do-Check-Act (PDCA) cycle, because such framework draws the deliberate and defined process for quality improvement in public health as it is focused on activities that are responsive to community needs. It refers to a continuous and ongoing effort to achieve measurable advancements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality services or processes that achieve increased and more equitable population health.⁶

PDCA cycles provide, in fact, a clear structure for iterative testing of changes to improve quality of systems:

Plan – design the change or progress to be tested or implemented,

Do – carry out the test or change,

Check – engage in a lively understanding of the extent of change and its (chances of) success,

Act – plan the next change cycle or full implementation on a broader scale, continue to monitor the change and iterate as necessary by repeating the cycle.

Building on the four core principles underpinning the IA2030 strategy—finalised to maximise the extension of benefits from vaccines to everyone, everywhere— which consist of putting people in the centre, countries in charge of leadership, implementation through broad partnerships, and data-based enabling process, we applied the PDCA model along the study period, 2021 to 2023 (Figure 1).

Figure 1.

Plan-Do-Check-Act cycle stages.

Plan (Stage 1) – Study Phase

The very base was about developing an understanding of the national vaccination scenarios in four European countries (Italy, Greece, Latvia, and Romania), analysing vaccine attitudes and behaviours, and factors underlying low coverage, especially in underserved communities, in general as well as during health emergencies (eg, the COVID-19 pandemic). To this aim, we designed a prototype reference grid to fill in with literature data on the three macro categories associated to vaccine hesitancy, or confidence, which are contextual elements, individual aspects, and vaccine-specific issues merging what has been retrieved by a much-cited peer-reviewed article listing key vaccine hesitancy determinants⁷ and prominent technical reports authored by the European Center for Disease Control and Prevention (ECDC).^8,9 Table 1 shows how the indicators were subcategorised, respectively, as related to the context (C) – influences arising due to historic, socio-cultural, environmental, health system/institutional, economic or political factors; individual (I) – influences arising from personal perception of the vaccine or influences of the social/peer environment; vaccine/vaccination (V).

Table 1.

Categorisation of Indicators Considered as Determinants to Vaccine Compliance.

Category	Determinant	Definition
(C) Influences arising due to historic, socio-cultural, environmental, health system/institutional, economic or political factors	Communication and media environment; negative exposure to media	Negative exposure to the media as a determinant of hesitation. Such exposures include having heard, read or seen, in the general media, unverified information and myths about vaccines.
	Influential leaders, immunisation programme gatekeepers and anti- or pro-vaccination lobbies; violation of human rights	Perception that vaccines are imposed on the population and violate human rights.
	Historical influences	Hesitation to vaccinate related to a specific historical period.
	Religion/culture/gender/socio-economic; religious fatalism	Religious fatalism that includes the belief that “we must trust in God’s decisions” or that human beings were created as they should have been and therefore vaccines are not needed
	Politics/policies	Fear that vaccines are introduced for government and political interests (specific mandates).
	Geographic barriers	Hesitation to vaccinate relative to a geographical area.
	Conspiracy theories	Conspiracy theories (in general).
	Perception of the pharmaceutical industry	Fear that vaccines are introduced to contribute to the economic interests of pharmaceutical companies.
(I) Influences arising from personal perception of the vaccine or influences of the social/peer environment	Personal, family and/or community members’ experience with vaccination, including pain; healthy bodies; previous negative experiences	Negative experience of previous vaccinations (personal and/or family).
	Beliefs, attitudes about health and prevention; vaccination not a priority; against vaccination in general; alternative prevention methods; diseases are beneficial; health bodies; low risk/severity of disease	Belief that there is a very low risk of contracting very serious diseases and clinical forms. The perception that the vaccine is not effective or able to prevent the disease. Belief that people are healthy enough to allow their immune system to be able not to need vaccinations.
	Knowledge/awareness; lack of information	Scarcity of information and knowledge leading sometimes to a distorted perception of vaccination risk.
	Health system and providers – trust and personal experience; mistrust in health institutions	Mistrust in health systems and in the provision of health services. General mistrust of the institutions.
	Risk/benefit (perceived, heuristic); responsibility if something bad happens; vaccine safety; vaccines not effective; fear of injection. Humans too weak to fight vaccine	Belief that vaccines are not safe. It is believed that they can cause serious diseases and side effects, that their long-term effect is unknown, that the risks are greater than the benefits.
	Immunisation as a social norm versus not needed/harmful Social norms	Social norms and pressure from family and friends (determinants of hesitation and not acceptance).
(V) Vaccine/vaccination-specific issues, directly related to vaccine or vaccination	Risk/benefit (epidemiological and scientific evidence); no medical need	Some people do not understand the risks/benefits of scientific evidence and the medical necessity of taking some vaccines.
	Vaccine novelty Introduction of a new vaccine or new formulation or a new recommendation for an existing vaccine	Refusal with respect to new vaccines or a new formulation and a consequent fear that vaccines are based on an insufficient number of tests and knowledge (low guarantee of effectiveness).
	Mode of administration	Fear of the way of administration of the vaccine.
	Design of vaccination programme/mode of delivery (eg, routine programme or mass vaccination campaign)	Hesitation with respect to the mode of administration/delivery of the vaccine.
	Reliability and/or source of supply of vaccine and/or vaccination equipment	Reliability of vaccine supply.
	Vaccination schedule	Tailor vaccines/vaccinations to needs.
	Access	Problem related to access in terms of time and availability of vaccines.
	Costs; financial cost	Economic cost-related issues.
	The strength of the recommendation and/or knowledge base and/or attitude of healthcare professionals; lack of recommendation from providers Inconsistent advice from providers	Lack of recommendations or inconsistency in the information provided by health professionals and poor communication skills of health workers.

We extracted data from 43 sources using the following headings: lead author, publication year, source type (ie, article, abstract, book, report), language, country/ies included, aim, study information (ie, design, participants, data collection, analysis), and findings (ie, M&E tool/framework used, indicators included, lessons described).

Do (Stage 2) – Implenting Phase

Building on the reference grid, we gathered existing vaccine communication and community engagement tools, in English and country languages, to help increase vaccine uptake and informing a web platform-based toolbox that, in turn, can be gradually updated and enriched as other communication tools are newly developed. Beside descriptive items of the tools (eg, year, source, determinants covered or subject disease), other evaluation criteria were included. Firstly, scored levels for text readability were assessed by a specific literature search on readability scores and evaluation methods. An expert librarian developed and validated the search by querying the collection “Health Research Premium Collection” (ProQuest), which enables research simultaneously in a database of bibliographic records, including the following databases: Consumer Health Database, Health & Medical Collection, Healthcare Administration Database, Medline, Nursing & Allied Health Database, Psychology Database, Public Health Database. Out of 170 pertinent records extracted, about 60% mentioned the Flesch-Kincaid Reading Ease and the Flesch–Kincaid Grade Level. We found a free website (https://goodcalculators.com/flesch-kincaid-calculator/) that offers both formulae. Whether the tool could be transformed in a Word document, it was also possible to use a Microsoft Word’s processing program with a function to calculate readability statistics on textual inputs based on the two Flesch-Kincaid formulae indicated above. The three readability levels identified the following thresholds: 1 – low (<40%); 2 – average (41-70%); 3 – high (>71%). The second evaluation element concerned the graphic layout assessed as positive (≥12) or negative (≤11) from the total count of the single score ranging from 1-poor to 5-high assigned to: Readability (eg, size of characters); Appropriateness (efficacy of graphic choice); Quality (use of colours and image definition); Impact (arrangement of text and figures). Lastly, the complexity was assessed as 1 – simple, 2 – average, 3 – very complex (ie, demanding advanced prior knowledge).

Check (Stage 3) – Verification Phase

The third step encompassed engaging in an interaction with a multistakeholder panel by a dedicated national vaccination roundtable including a media training. The discussion revolved around the ways to improve vaccine uptake in different target groups, by involving the relevant stakeholders in the field such as national and regional health authorities, health professionals, researchers, civil society representatives and citizens’ associations.

Act (Stage 4) – Co-creating Phase

The fourth step, that actually according to a circular approach gives input to a new cycle, concerned co-developing (or even co-selecting) a tool and piloting it amongst the identified target communities to support efforts for vaccine uptake and equity improvement, under a longer sustainability perspective, and above all tailored to specific population groups, vaccines and national scenarios.

Results

Plan (Stage 1)

Figure 2 provides the PRISMA flow diagram of the results from reviewing both scientific and grey literature on national vaccination scenarios in four European countries (Italy, Greece, Latvia, and Romania). Overall, among the screened sources, the final amount of records included was 57: 49 out of 95 peer-reviewed items and eight non-peer reviewed reports out of 47.

Figure 2.

PRISMA flow diagram.

The present paper considers the 34 out of 49 scientific studies which took place exclusively in Italy (29) or included Italian population samples within European-based initiatives (5) in the decade 2011 to 2021 (Table 2).^10-43 The most studied vaccinations were against influenza (n = 13; 38%), HPV (n = 6; 18%), and COVID-19 (n = 4; 12%). Six studies addressed early childhood vaccines and only one examined vaccinations to health professionals. Four articles analysed all vaccines, on the contrary one focused on varicella and another on measles. With regard to the factors described, on the one hand a total of 15 studies (44%) addressed the determinants combined: three on triple category (contextual, individual, vaccine), whereas different distribution occurred for the double issue (n = 9/26% considered individual and vaccine-specific aspects, two scientific papers explored contextual and individual determinants, and one context- and vaccine-related patterns). On the other hand, among manuscripts concentrating only on one category, 14 (41%) reported findings on individual factors, three on elements related to the vaccine(s) under investigation and two to the context. The most covered topics concerned knowledge foundation, awareness and risk perception, attitudes and behaviours around vaccinations, with focus on barriers or enablers to uptake, according to the specific perspective of target population (eg, health professionals or parents on childhood vaccines).

Table 2.

Synthesised Literature Findings by Italian Studies.

Lead author, year	Study type	Study period	Population, location	Vaccine/disease	Sample size (M/F%)	Response rate (%)	Age (mean/SD/median/range)	Outcomes under study	Tools or data sources used	Vaccine determinants
Amodio, 2011	Cross-sectional study	Sept.-Oct. 2010	Medical residents attending post-graduate school at the University of Palermo, Sicily, Italy	Influenza vaccine	202 (34/66)	202/302 (66.9)	Mean/SD: 28.7/3.3	Knowledge, attitudes and perceptions on seasonal and pandemic influenza vaccination.	Self-administered, anonymous web-based questionnaire	I
Bertoldo, 2019	Cross-sectional study	Mar.-June 2017; Feb.-Apr. 2018	Adults with chronic diseases, Naples, Italy	Influenza vaccine	700 (45/54)	700/712 (98.3)	Mean/SD: 58.6/19.2	Knowledge and attitudes on influenza vaccination and its uptake determinants.	Self-administered questionnaire	I, V
Bertoncello, 2020	Cross-sectional study	Dec. 2016-Apr. 2017	Parents of children aged 3 months to 7 years, in Italy	Vaccines for children	3865	NR	Mean/SD Fathers: (40.1/5.7); Mean/SD Mothers: (37.4/4.9)	Socioeconomic inequalities in vaccine hesitancy and outright refusal.	Online questionnaire	I, V
Bianchi, 2020	Retrospective cohort study	Dec. 2017-Jan. 2019	HPs, General University-hospital, Bari, Italy	Recommended vaccines to HPs	449 (365/64)	NR	Mean/SD: 38.6 ± 10.7	HPs immunity to VPDs and vaccine compliance.	Data from the biological risk assessment program	V
Caserotti, 2021	Cross-sectional study	Feb.-June 2020	General population, Italy	COVID-19 vaccine; Influenza vaccine	2267 (30/70)	2267/3691 (61.4)	Mean/SD: 38.1/14	Risk perception and intention to vaccinate for seasonal flu and COVID-19 pre, during and after pandemic lockdown.	Questionnaire	I
Cocchio, 2020	Cross-sectional study	Oct. 2015-June 2016	General population, University students, Italy	HPV vaccine	9988 (40/60)	9998/11096 (90)	Mean/SD: 20.5/1.81	Associated factors to HPV vaccine intention.	Self-administered, anonymous questionnaire	I
Coniglio, 2011	Cross-sectional study	Oct.-Dec. 2008	Parents of children aged 3 and 5 years, Catania, Italy	Vaccines for children	1218 (7/93)	1218/1500 (81.2)	Parents’ range: 31-40	Acceptance or non-acceptance of recommended vaccination for children.	Self-administered questionnaire	C, I, V
Costantino, 2014	Cross-sectional study	Apr.-June 2012	Medical residents attending post-graduate schools of 18 Italian Universities	Influenza vaccine	2506 (35/65)	2506/10396 (24.1)	Median: 29	Attitudes and determinants associated with influenza vaccine acceptance.	Self-administered, anonymous web-based questionnaire	I, V
Costantino, 2020	Cross-sectional study	Apr. 2017	General population, Palermo, Italy	All vaccines	299 (37/63)	NR	Mean/SD: 40/14.2	Knowledge, attitudes, and behaviours on vaccines.	Anonymous questionnaire	I
Dalma, 2018^(EU)	Qualitative study	Oct. 2013-Jan. 2014	HPs and policy-makers from some countries including Italy.	Booster (MMR, varicella, hepatitis B, Td, Tdap vaccines), seasonal and pandemic influenza vaccines.	278	NR	NR	Barriers, enablers, perceptions and needs to develop tailored educational toolkits for better vaccine coverage among European HPs.	Focus groups	C, V
de Figueiredo, 2020^(EU)	Retrospective study	Sept. 2015-Dec. 2019	General population	All vaccines	284381	NR	NR	Global trends in vaccine confidence.	Large-scale retrospective data-driven analysis from 290 surveys	C, I
Della Polla, 2020	Cross-sectional study	Apr.-Oct. 2019	Parents of adolescents aged 12 to 13 years, Naples and Salerno, Italy	HPV vaccine	435 (25/75)	435/550 (79.1)	Mean/SD: 44.3/5.8	HPV vaccine hesitancy and its determinants.	Self-administered questionnaire; Parent Attitudes about Childhood Vaccine Survey (PACV)	I
Desiante, 2017	Cross-sectional study	Feb.-Mar. 2016	GPs, Taranto, Italy	Influenza vaccine	229 (21/79)	229/471 (48.6)	Median 59.6	Influenza vaccine uptake and influencing factors.	Self-administered web-based standardised questionnaire	I
Durando, 2016	Cross-sectional study	Oct. 2013-Feb. 2014	HPs from an Italian Region (Liguria, Italy)	Influenza vaccine	830 (70/30)	830/8248 (10.1)	Mean/SD: 46.8/8.7	Knowledge, beliefs and attitudes associated with 2013/2014 seasonal flu vaccination uptake.	Anonymous self-administered web questionnaire	C
Fabiani, 2019	Retrospective cohort study	Oct. 2016-Jan. 2017	General population aged ≥ 65, Lazio, Italy	Influenza vaccine	1255657 (42/57)	NR	Range: 65-≥90	Association between 2016 and 2017 influenza vaccine uptake in elderly population and GPs demographic/professional characteristics.	Health administrative data sources	I, V
Gallone, 2017	Case-control study	Apr. 2014	Students Bari University, Italy	Influenza vaccine	669 (46/54)	NR	Mean/SD: 23.9/4.9	Vaccine compliance determinants.	Online anonymous questionnaire	V
Giambi, 2018	Cross-sectional study	Dec. 2015-June 2016	Parents of children aged 16 to 36 months, five Regions, Italy	Vaccines for children	3130	3130/3230 (97)	Mean/SD Fathers:(37.5/6.1); Mean/SD Mothers: (34.6/5.4)	Parental vaccine hesitancy and its determinants.	Questionnaire administered online or self-administered at paediatricians’ offices and nurseries	I, V
Giuliani, 2016	Cross-sectional study	Apr.-June 2013	High-risk men, attendees of the largest STI Center in Rome, Italy	HPV vaccine	423	423/502 (84.3)	Median: 33	Awareness of HPV infection and acceptability.	Self-administered anonymous questionnaire	I
Gualano, 2018	Cross-sectional study	Sept. 2016-May 2017	Pregnant women, 15 cities, Italy	Vaccines for children	1820	NR	Mean/SD: 32.5/5.2	Attitudes and behaviours towards mandatory paediatric vaccinations.	Questionnaire administered by two trained doctors	C
Karafillakis, 2019^(EU)	Systematic review	2005-2016	European countries. Data from Italy, Romania and Greece were included	HPV vaccine	103 articles	NR	NR	Determinants of HPV vaccine hesitancy in Europe.	Systematic literature review	C, I, V
Karnaki, 2019^(EU)	Cross-sectional study	Oct. 2012-Apr. 2014	HPs in 14 EU countries, including Italy (n = 251).	Recommended vaccinations for HPs	5424 (19.1/80.9)	5424/5553 (97.7)	NR	Vaccine attitudes and behaviours for a number of VPDs.	Online anonymous questionnaire	I, V
Keske, 2020^(EU)	Cross-sectional study	May-July 2019	ICT^ members, 56 countries including Italy	Influenza vaccine	899 (32/68)	NR	Mean/SD: 44.2/10.76	Opinion on influenza vaccination and related factors affecting perceptions.	Self-administered online survey	I
Ledda, 2021	Cross-sectional study	Sept.-Dec. 2020	HPs, Catania University Hospital, Italy	VPDs; COVID-19 vaccine	787 (47/53)	798/787 (99)	Range: ≤30-≥51	HPs knowledge and attitudes on VPDs 1) during 2) before COVID-19 pandemic.	Self-administered questionnaire	I
Ledda, 2021	Cross-sectional study	Jan.-Dec. 2019	HPs, Catania University Hospital, Italy	VPDs	1323 (48/52)	1323/1354 (98)	Range: ≤30-≥51		Self-administered questionnaire	I
Lo Vecchio, 2019	Cross-sectional study	Nov. 2016-Mar. 2017	Paediatric patients, Southern Italy	Measles vaccine	1141 (47/53)	1141/1276 (89.4)	Median: 86 months	Determinants of missed children vaccination in the 2016 outbreak.	Standardised face-to-face questionnaire	I
Montalti, 2021	Cross-sectional study	Dec. 2020-Jan. 2021	Parents/guardians of children <18 years old, Bologna, Italy	Law 119/2017 vaccines for children; COVID-19 vaccine	4993 (23/77)	4993/5054 (98.8)	Range: ≤329-≥50	COVID-19 vaccine hesitancy determinants.	Questionnaire	C, I
Napolitano, 2016	Cross-sectional study	Jan.-Apr. 2015	Adolescents/young male adults (high-school and university students), geographic area of Naples and Caserta, Italy	HPV vaccine	956	956/1000 (95.6)	Mean/SD: 19.6/3.1	Knowledge and the attitudes on HPV and the relative vaccination and to investigate their determinant.	Self-administered anonymous questionnaire	I
Napolitano, 2018	Cross-sectional study	Sept. 2016-Mar. 2018	Immigrant and refugees, Naples, Italy	HPV vaccine	427 (49/51)	427/519 (82.3)	Mean/SD: 32.4/12.8	Knowledge and attitudes on HPV and vaccine, impact of determinants.	Questionnaire administered by two researchers	I
Prospero, 2018	Cross-sectional study	Oct. 2016-Jan. 2017	Pregnant women, Marche, Italy	Influenza vaccine	366	366/377 (97)	Mean/SD: 32/0.27	Barriers to influenza vaccine.	Self-administered questionnaire	C, I, V
Reno, 2021	Cross-sectional study	Jan. 2021	General population, Emilia-Romagna, Italy	COVID-19 vaccine	1011 (45/55)	NR	Mean/SD: 46.9/11.5	Predictors of COVID-19 vaccine hesitancy.	Questionnaire	I
Rosso, 2019	Cross-sectional study	Apr. 2016-Apr. 2017	Pregnant women, Rome, Italy	Vaccines for children	458	458/466 (98.3)	Mean/SD: 32.9/5.0	Vaccine hesitancy and its determinants.	Self-administered questionnaire	I, V
Santangelo, 2020	Cross-sectional study	May 2019	Nursing students, Palermo University, Italy	Influenza vaccine	403 (35/65)	403/409 (98.5)	Mean/SD: 22.02/3.04	Vaccine uptake determinants.	Anonymous paper questionnaire.	I, V
Scatigna, 2016	Cross-sectional study	Apr.-May 2015	Hospital HPs, L’Aquila, Italy	All vaccines	334 (28/72)	334/1081 (30.9)	Range: ≤329-≥60; 57.1% were aged 40 to 59	VPD vaccination coverage rates and determinants as 1. Personal responsibility in HPs vaccination; 2. Beliefs on preventive usefulness of vaccines; 3. Beliefs on vaccines-related risks; 4. Perceived susceptibility to infectious diseases.	Anonymous questionnaire self-reported.	I
Vezzosi, 2017	Cross-sectional study	May-June 2015	Parents of children aged 4 to 7 years in the geographic area of Naples, Italy	Varicella vaccine	414 (27/73)	414/675 (61.3)	Mean/SD: 40.4/6	Knowledge on varicella infection, knowledge, attitudes and behaviour on vaccine and determinants.	Self-administered anonymous questionnaire	I, V
Vimercati, 2019	Cross-sectional study	Oct. 2016-Jan. 2018	HPs of Bari Policlinico, Italy	Influenza vaccine	295 (49.5 50.5)	NR	Mean/SD: 43.4/13.5	Influenza vaccination coverage.	Official list of vaccinated HPs	V
Vimercati, 2019	Cross-sectional study	Oct. 2016-Jan. 2018	HPs of Bari Policlinico, Italy	Influenza vaccine	482 (49.2/50.8)	NR	Mean/SD: 45.5/13.2	Influenza vaccination coverage.	Official list of vaccinated HPs	V

Abbreviations: C, contextual vaccine determinants; EU, European studies; GPs, general practitioners; HPs, health professionals; I, individual vaccine determinants; ICT, Infection Control Team advocating for influenza vaccination among HPs; NR, not reported; V, vaccine-specific determinants; VPDs, vaccine preventable diseases.

Do (Stage 2)

From the 204 heterogeneous vaccine communication tools collected overall across the four countries or at international level, 42 related to Italy. Table 3 shows characteristics for the Italian tools which relate to the decade 2013 to 2022. The most part was issued by institutional actors such as the Ministry of Health (n = 28; 67%) and other two by a governmental body; six tools (14%) were released by the Italian Society of Hygiene, Preventive Medicine and Public Health, five (12%) by Paediatrics Association or Hospital, and one by several groups altogether. Differently from the scientific studies, vaccine communication tools addressed mostly single determinants: 18 tools (43%) vaccine-specific patterns, ten (24%) contextual factors, and nine (21%) individual-related elements. Combination of factors were addressed as follows: three tools individual and vaccine issues, one on context and vaccine, and another on context and individual perspective. These tools mainly targeted general population (67%) and in a certain measure specific groups such as parents, as vaccine preventable diseases (VPDs) were generically indicated or specific vaccinations recalled were measles, COVID-19, HPV, rubella. In more than half of cases (55%), the communication format was poster, other similar versions such as leaflet or booklet covered 21% of the tools, and multimedia material consisted of seven videos. The readability score was possible to apply to the half of tools retrieved: 13 got more than 75, 5 were assessed with medium points (>50), two by low values and one resulted with negative number.

Table 3.

Italian Vaccine Communication Tools.

Title	Year	Source	Determinants	Disease	User	Target	Type	Readability	Layout	Endorsement	Complexity
Facciamolo per noi	2021	Government, Presidency of the Council of Ministers	I, V	COVID-19	N/A	General population	Multimedia – Video	N/A	N/A	N/A	1
Riprendiamoci il gusto del futuro	2021	Government, Presidency of the Council of Ministers	I, V	COVID-19	N/A	General population	Multimedia – Video	N/A	N/A	N/A	1
I vaccini funzionano!	2019	Ministry of Health	I	N/A	N/A	General population	Poster	72.9	Positive	Italian Medicines Agency (AIFA)	1
Condividere i fatti sui vaccini aiuta a salvare le vite	2019	Ministry of Health	C	N/A	N/A	General population	Poster	65.7	Positive	Italian Medicines Agency (AIFA)	1
La vaccinazione protegge la salute	2019	Ministry of Health	I	N/A	N/A	General population	Poster	77.3	Positive	Italian Medicines Agency (AIFA)	1
Stop HPV	2019	Ministry of Health	V	HPV	N/A	Women	Poster	76.7	Positive	Italian Medicines Agency (AIFA)	1
Stop HPV 2	2019	Ministry of Health	V	HPV	N/A	Women	Poster	80.7	Positive	Italian Medicines Agency (AIFA)	1
Insieme possiamo eliminare la poliomielite	2019	Ministry of Health	V	Polio	N/A	General population	Poster	76.7	Positive	Italian Medicines Agency (AIFA)	1
La pertosse è particolarmente grave nei neonati	2019	Ministry of Health	V	Pertussis	Parents	Newborns	Poster	92.3	Positive	Italian Medicines Agency (AIFA)	1
Morbillo	2019	Ministry of Health	C	Measles	N/A	General population	Poster	50.4	Positive	Italian Medicines Agency (AIFA)	1
Morbillo 2	2019	Ministry of Health	C	Measles	Parents	Children	Poster	12	Positive	Endorsed by the Italian Medicines Agency (AIFA)	1
Genitori, #VacciniHeroes	2019	Ministry of Health	I	N/A	N/A	General population	Poster	64.9	Positive	Italian Medicines Agency (AIFA)	1
Gli operatori sanitari	2019	Ministry of Health	I	N/A	N/A	Health professionals	Poster	58.3	Positive	Italian Medicines Agency (AIFA)	1
Il morbillo è una malattia seria	2018	Ministry of Health	V	Measles	N/A	General population	Poster	N/A (visual input interference)	Positive	Italian Medicines Agency (AIFA)	1
Poster generico	2018	Ministry of Health	I	N/A	N/A	General population	Poster	N/A (visual input interference)	Positive	Italian Medicines Agency (AIFA)	1
Immunità di gruppo	2018	Ministry of Health	I	Measles	N/A	General population	Poster	N/A (visual input interference)	Positive	Italian Medicines Agency (AIFA)	1
Come funzionano i vaccini	2018	Ministry of Health	I	N/A	N/A	General population	Poster	N/A (visual input interference)	Positive	Italian Medicines Agency (AIFA)	1
Rosolia	2018	Ministry of Health	V	Rubella	N/A	Childbearing age women	Poster	N/A (visual input interference)	Positive	Italian Medicines Agency (AIFA)	1
Volantino Finale	2018	Ministry of Health	V	N/A	N/A	General population	Poster	N/A (visual input interference)	Positive	Italian Medicines Agency (AIFA)	1
Il vaccino MPR combina 3 vaccinazioni in 1	2018	Ministry of Health	V	Measles, mumps, rubella	Parents	Children	Poster	N/A (visual input interference)	Negative	Italian Medicines Agency (AIFA)	2
Vaccini per adulti	2018	Ministry of Health	V	N/A	N/A	Adult population	Flyer	91.6	Positive	Italian Medicines Agency (AIFA)	1
Sagome umane	2018	Ministry of Health	I	N/A	N/A	General population	Poster	33.2	Positive	Italian Medicines Agency (AIFA)	1
Il morbillo è una malattia seria 2	2018	Ministry of Health	V	Measles	N/A	General population	Poster	N/A (visual input interference)	Negative	Italian Medicines Agency (AIFA)	2
La vaccinazione è il modo migliore per acquisire l’immunità al morbillo	2018	Ministry of Health	V	Measles	N/A	General population	Poster	N/A (visual input interference)	Negative	Italian Medicines Agency (AIFA)	2
Il morbillo è una seria minaccia per la salute	2018	Ministry of Health	V	Measles	N/A	General population	Poster	N/A (visual input interference)	Negative	Italian Medicines Agency (AIFA)	2
Facciamo squadra per la nostra salute	2018	Ministry of Health	I, V	Measles	N/A	General population	Multimedia – Video	N/A	N/A	N/A	1
Un consiglio da campione	2018	Ministry of Health	I	N/A	N/A	General population	Multimedia – Video	N/A	N/A	N/A	1
Parliamo di esitazione. Accrescere la fiducia nella vaccinazione e le coperture vaccinali	2018	Ministry of Health	I, C	N/A	Health professionals	General population	Booklet	88.6	Positive	N/A	1
Parliamo di protezione. Migliorare le coperture delle vaccinazioni pediatriche	2018	Ministry of Health	V	Several (Pediatric)	Health Professionals	Parents	Booklet	94.9	Positive	N/A	1
Il “PASSAPORTO VACCINALE” dell’adolescente: dal pediatra al Medico di Famiglia	Any date indicated	Federation of Medical Paediatricians	V	Several (Adolescent)	Parents	Adolescents	Flyer	89.2	Positive	N/A	1
Vaccinazione anti-HPV: evidenze, critictà, proposte	Any date indicated	Federation of Medical Paediatricians	V	HPV	Paediatricians	Parents	Multimedia – Video	N/A	N/A	N/A	1
Perché vaccinare tuo figlio Adolescente contro COVID 19	2021	Federation of Medical Paediatricians	V	COVID-19	Paediatricians	Parents	Flyer	96.7	Positive	N/A	1
I VACCINI e LE VACCINAZIONI	Any date indicated	Societies/Federations: Pharmacology; Hygiene, Preventive Medicine and Public Health, Paediatricians and general Practitioners	C, V	All	Paediatricians	Parents	Booklet	N/A	Positive	National Institute of Public Health and Ministry of Health	3
Guida pratica alle VACCINAZIONI	2014	Society of Preventive and Social Paediatrics	V	Several (Pediatric)	Paediatricians	Parents	Booklet	N/A	Positive	National Institute of Public Health and Ministry of Health	2
VaccinarSì – protecting health of all from the disinformation of fews	2013	Society of Hygiene, Preventive Medicine and Public Health	C	N/A	N/A	General population	Bookmark	93.4	Positive	National Institute of Public Health and Ministry of Health	1
VaccinarSì – protecting health of all from the disinformation of fews	2013	Society of Hygiene, Preventive Medicine and Public Health	C	N/A	N/A	General population	Poster	93.4	Positive	National Institute of Public Health and Ministry of Health	1
VaccinarSì – protecting health of all from the disinformation of fews	2013	Society of Hygiene, Preventive Medicine and Public Health	C	N/A	N/A	General population	Flyer	98	Positive	National Institute of Public Health and Ministry of Health	1
VaccinarSì – “Storie di. . .”	2014-2015	Society of Hygiene, Preventive Medicine and Public Health	C	All	N/A	General population	Web resources (general)	N/A	Negative	National Institute of Public Health and Ministry of Health	1
VaccinarSì – Video	Any date indicated	Society of Hygiene, Preventive Medicine and Public Health	C	N/A	N/A	General population	Multimedia – Video	N/A		National Institute of Public Health and Ministry of Health	1
VaccinarSì – COMx TRUE	Any date indicated	Society of Hygiene, Preventive Medicine and Public Health	C	N/A	N/A	General population	Comics	−1.5	Positive	National Institute of Public Health and Ministry of Health	1
Vaccinazioni – Il bambino	Any date indicated	Paediatric Hospital Bambino Gesù	C	All	N/A	General population	Web resources (general)	N/A	Positive	N/A	1
“Facciamolo per noi”	2022	Ministry of Health	V	COVID-19	N/A	General population	Multimedia – Video	N/A	Positive	Ministry of Health	1

Abbreviations: C, contextual vaccine determinants; I, individual vaccine determinants; N/A, not applicable; V, vaccine-specific determinants.

Check (Stage 3)

A participatory dialogue and direct engagement with national stakeholders, media included, was developed to discuss communication tools for improving vaccine uptake in different populations, in particular vulnerable and underserved groups.

The Italian roundtable took place at the premises of the National Institute of Health, namely Istituto Superiore di Sanità (ISS), in Rome on June 13, 2022 and saw the participation of 11 reference persons representing eight stakeholder categories: institutional as Ministry of Health, Ministry of Education, and ISS Press Office; health professionals (General Practitioners, Nurses, and Pharmacists); Civil Society Organisations as Active Citizenship and School Principals. The Italian stakeholder roundtable particularly focused, in fact, on the role that schools can have in improving levels of awareness and compliance with vaccinations in the students’ community as well as in their families, broadening to a large part of the whole population. Based on the ISS platform for professional training, the gathered stakeholders agreed that it could be viable to build up a digital library/repository of validated materials on vaccinations that can be useful to teachers and students. Training courses can address these issues, providing teachers with communication competences, which are fundamental in the promotion of vaccinations among school-aged children and their families. ISS envisaged the school setting as appropriate context for action, even taking advantage from the long lasting alliances with both Ministries and health authorities (centrally) and the third sector (locally). Furthermore, the national roundtable was associated to a media training that in the case of Italy concerned the main figures about misconceptions related to journalistic approaches to vaccine communication. The focus of the training was on how to improve cooperation between experts and journalists, and how to effectively communicate through modern media reliable information on vaccination and health policies to protect the public from infectious diseases. Participants also discussed how to effectively create social campaigns and reach out to specific social groups. They also analysed the most common fake news about vaccination and together came up with methods to dispel harmful myths and lies about immunisation.

Act (Stage 4)

After the three previous phases (studying national scenarios, gathering vaccine toolboxes, engaging with relevant stakeholders in the field), co-creation and/or co-selection of tools on vaccine communication to pilot followed, both focusing on particular vaccinations and certain population groups, such as the school setting for the Italian node.

In Italy, in fact, vaccine-related issues are not specifically addressed in schools despite this setting is ideal to effectively reach out several target groups (students but also their families, teachers and other school professionals). In this framework, the scope of action was about raising vaccine awareness among secondary school-aged children (10-19 years old) in the Lazio Region, and related groups as indicated (eg, teachers and students’ families). After the national roundtable and the appropriate evaluation of stakeholders’ considerations, the association of school headmasters was engaged to further discuss and exchange ideas and perspectives. In order to better address contents to discuss in a face-to-face meeting, a rapid survey targeted teachers, students, and parents by administering three different web-based questionnaires. Topics investigated were: preferred information sources about vaccines and vaccinations; knowledge, attitudes and practices on indicated vaccines (diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B, Haemophilus influenzae type b infection, pneumococcal disease, measles, mumps, rubella, varicella, meningococcal disease, influenza, herpes zoster, hepatitis A, COVID-19); school engagement and efforts in matter of VPDs; media voice and myths around vaccinations. The total respondents, n = 89, (respectively, 27 students, 28 teachers, and 34 parents confirmed that school can play an active role and serve as privileged context to provide not only vaccine information but also vaccination practice. Selected representatives of the target groups identified were invited in an innovative setting such as the Scientific Museum of ISS on December 12, 2022, to further elaborate on the survey results and figure out possible educational material to develop. Teachers and students were engaged in a lively discussion on health information literacy in general and in particular on vaccine communication tools, by soliciting reasoning about vaccines and vaccinations as relevant disease prevention and public health issue to further embed in the Italian schools. A recognised example as feasible implementation case was the promotion of HPV vaccination.

Discussion

The experience described in matter of pooling vaccine communication actions to promote vaccination in Italy according to the PDCA cycle allows several considerations, even in the light of the comparison with experiences from other countries, which this process and its variations^44-46 resulted to be challenging to apply within real implementation programs, up to cases such as reported by Manyazewal et al⁴⁷ who included the use of the PDCA cycle in a continuous quality improvement intervention for a vaccination programme in Ethiopia or Aceituno et al⁴⁸ who used a logical framework to determine participant engagement in Bolivia.

The first scope of the specific focus on the PDCA framework applied to the Italian context was to highlight to what extent it is fundamental to run the four-stage cycle consistently in order to deliver effective and impactful vaccine communication. Furthermore, the particular matter of vaccine communication has to be necessarily included in the national vaccination strategies which, in turn, need to be considered as a whole. A study on communication implementation in the H1N1 pandemic influenza outbreak in Italy in 2009 found a lack of planning and a low value attached to the skills required to produce effective communications. As also in other two countries, there was a dearth of good quality audience research to inform the development of communications. Little thought had been given to the tone, targeting or channelling of messages. Instead, communications were characterised by a “one size fits all” and a “top down,” expert-led response. There was also little effort to evaluate the impact of communications, but where this was done, very low levels of public compliance and engagement with key behavioural messages were found.⁴⁹ Such low adherence to communication principles specifically applied to vaccine policies and strategies can be retrieved even in a recent assessment of the national coverage for different vaccinations in Italy in the last 25 years. The acting Ministers and Chief Medical Officers from 1999 to date analysed five consecutive National Vaccination Prevention Plans (1999/2000, 2005-2007, 2012-2014, 2017-2019, 2023-2025) and commented on the quite heterogeneous situation in Italy: whereas childhood vaccinations approached target levels, though regional differences, others such as for adolescents, the elderly, and vulnerable individuals consistently fell short of targets. This result is linked to the ambitious and well-planned vaccination policies in Italy over the past 25 years which successfully impacted, onto newborns immunisation, but conversely causes for failure to achieve goals for other groups have to be searched also among inconsistent implementation of the Regional Vaccination Prevention Plans.⁵⁰

Linking up to the concept expressed earlier, about the need to look at the vaccination chain as a whole that necessarily considers the vaccine communication lever, in Italy large population-based surveillance systems are in place to monitor continuously behavioural multirisk factors in adults and older individuals, and represent valuable data sources even to detect several vaccine-related aspects. This applied to vaccine flu compliance among health professionals,⁵¹ disparities for rubella vaccination coverage among Italian versus migrant childbearing-age women,⁵² associations between vaccination against influenza and health literacy level in regional subsamples⁵³ or, during the last pandemic, to understand the COVID vaccine confidence in the elderly.⁵⁴

In the last years, health literacy has been conceptualised as a social vaccine in the context of the COVID-19 pandemic but, when exploring the vaccine-specific health literacy, so called vaccine literacy, among the general population, some particular drivers characterise this subarea of the general health literacy. Both the theoretical and experimental scientific debate has been deepening and increasingly led to understand that general health literacy and its specific forms such as vaccine literacy only partially but not completely overlap. It means that highly health literate people may not show high vaccine literacy, and the two forms of literacy (general and vaccine-specific) tend to differ as per weight in predicting some health or health-related outcomes. Therefore, health- and vaccine-literacy need to be considered as partially interweaving knowledge, skills and competencies relating to vaccinology that deals with several issues including wide ranged disciplines, from biology and epidemiology up to human and social sciences. In turn, such complexity is associated to the vaccination rationale that is about individual and community health protection. Vaccines do represent, in fact, primary prevention tools on healthy people who are called to assumption of responsibility and decision on themselves or for others (e. g., parents to their children) and, as shown in this study predictors to vaccination uptake or acceptance may significantly differ from levers for other health behaviours.⁵⁵

It seems then fundamental that to appreciate the real progress in terms of vaccine communication, beside the implementation of a comprehensive and well-designed strategy such as the PDCA framework here presented, as also Others have suggested indicating ten actions to counteract vaccine hesitancy in Italy,⁵⁶ diverse systems or procedures for disease prevention and health promotion need to be considered according to a holistic approach. In the present study, some of the measures proposed by the Italian Society of Hygiene, Preventive Medicine, and Public Health encompassing the role of vaccine communication are retrievable, namely in establishing multidisciplinary working groups, recognising local and national best practices, focusing on professional training and promoting both collaborations between scientific societies and knowledge from behavioural sciences.

Limitations

The exercise about pooling vaccine communication actions to promote vaccination in Italy shows the ideal cycle to put in place according to the PDCA model. However, to commute theory to practice, each step is approximated at the better solution but some limitations apply such as, firstly, the different scale through the PDCA cycle is developed. Where it was adopted the national perspective, part of the evidence retrieved referred to subnational levels, that is, regional or local (eg, single hospital). Additionally, to indicate how effective the health communication is, readability of not all tools can be assessed by using the Flesch-Kincaid formulae.

Conclusions

Through a broad perspective to look at vaccine communication, it emerged how vaccine hesitant or confident behaviours in the different population groups are associated to determinants which apply to contextual, individual, and vaccine-specific issues. Thus, the elaboration process of vaccine communication tools need to be designed and developed building on available and updated evidence, as well as used and assessed in a coordinated, integrated and collaborative multistakeholder and intersectoral scenario. Vaccine literacy improvement passes through sustainable and synergic life course interventions, including continuous training to health professionals. Physicians and other healthcare workers have the huge potential to be a mighty force in fighting infodemics and reversing hesitancy toward vaccination, but to gain health it is necessary that communities continuously collaborate, partner, and support each other, to do what one sector could never do as effectively on its own. Such complex reasoning appears even more relevant when the discussion is about vaccines and vaccination policies.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251342097 – Supplemental material for Pooled Vaccine Communication Actions to Promote Vaccination in the European Union: The Case of Italy

Supplemental material, sj-docx-1-jpc-10.1177_21501319251342097 for Pooled Vaccine Communication Actions to Promote Vaccination in the European Union: The Case of Italy by Valentina Possenti, Roberto Croci, Roberta Terlizzi, Annina Nobile, Luca Fucili, Marco Mirra, Stefano Lucattini, Massimiliano Di Gregorio, Anna Maria Giammarioli, Scilla Pizzarelli, Francesco Corea, Antonio Mistretta, Paola De Castro and Raffaella Bucciardini in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We truly wish to thank EuroHealthNet staff who coordinated the EU-funded project “Improving IMMunisation cooperation in the European UNION” in the persons of Caroline Costongs, Alison Maassen, Alba Godfrey, David Hargitt as well as all participating Partners.

ORCID iDs

Valentina Possenti

Luca Fucili

Scilla Pizzarelli

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research refers to some actions developed within “Improving IMMunisation cooperation in the European UNION” that has been receiving funds by the European Union’s 3rd Health Programme, 2014-2020, under grant agreement number 101018210.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Please, contact the corresponding author for specific information requests on data presented.

Supplemental Material

Supplemental material for this article is available online.

References

World Health Organization. Assessing and Improving the Accuracy of Target Population Estimates for Immunization Coverage. World Health Organization; 2015.

World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind. World Health Organization; 2020. Accessed December 23, 2024. https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030

World Health Organization. IA2030 Immunization Agenda 2030: Monitoring and Evaluation Framework 2021. World Health Organization; 2021. Accessed December 23, 2024. https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030

Marzouk

Omar

Sirison

, et al. Monitoring and evaluation of national vaccination implementation: a scoping review of how frameworks and indicators are used in the public health literature. Vaccines. 2022;10:567. doi:10.3390/vaccines10040567

Coalition for Vaccination. Accessed December 23, 2024. https://coalitionforvaccination.com/

U.S. Centers for Disease Control and Prevention (CDC). Performance Management & Quality Improvement: Resources. Models, Tools and Methods. Accessed May 14, 2025. https://www.cdc.gov/public-health-gateway/php/communications-resources/performance-management-quality-improvement-resources.html

MacDonald

NE.

Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036

European Centre for Disease Prevention and Control. Let’s Talk about Hesitancy – Enhancing Confidence in Vaccination and Uptake: 2016. 2016. Accessed December 23, 2024. https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/lets-talk-about-hesitancy-vaccination-guide.pdf

European Centre for Disease Prevention and Control. Let’s talk about protection. Enhancing childhood vaccination uptake. Communication guide for healthcare providers: 2016. 2016. Accessed December 23, 2024. https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/lets-talk-about-protection-vaccination-guide.pdf

10.

Amodio

Tramuto

Maringhini

, et al. Are medical residents a “core group“ for future improvement of influenza vaccination coverage in health-care workers? A study among medical residents at the University Hospital of Palermo (Sicily). Vaccine. 2011;29(45):8113-8117. doi:10.1016/j.vaccine.2011.08.033

11.

Bertoldo

Pesce

Pepe

Pelullo

Di Giuseppe

; Collaborative Working Group. Seasonal influenza: knowledge, attitude and vaccine uptake among adults with chronic conditions in Italy. PLoS ONE. 2019;14(5):e0215978. doi:10.1371/journal.pone.0215978

12.

Bertoncello

Ferro

Fonzo

, et al. Socioeconomic determinants in vaccine hesitancy and vaccine refusal in Italy. Vaccines. 2020;8(2):276. doi:10.3390/vaccines8020276

13.

Bianchi

Vimercati

Mansi

, et al. Compliance with immunization and a biological risk assessment of health care workers as part of an occupational health surveillance program: the experience of a university hospital in southern Italy. Am J Infect Control. 2020;48(4):368-374. doi:10.1016/j.ajic.2019.09.024

14.

Caserotti

Girardi

Rubaltelli

Tasso

Lotto

Gavaruzzi

Associations of COVID-19 risk perception with vaccine hesitancy over time for Italian residents. Soc Sci Med. 2021;272:113688. doi:10.1016/j.socscimed.2021.113688

15.

Cocchio

Bertoncello

Baldovin

, et al. Awareness of HPV and drivers of HPV vaccine uptake among university students: a quantitative, cross-sectional study. Health Soc Care Community. 2020;28(5):1514-1524. doi:10.1111/hsc.12974

16.

Coniglio

Platania

Privitera

Giammanco

Pignato

Parents’ attitudes and behaviours towards recommended vaccinations in Sicily, Italy. BMC Public Health. 2011;11:305. doi:10.1186/1471-2458-11-305

17.

Costantino

Caracci

Brandi

, et al. Determinants of vaccine hesitancy and effectiveness of vaccination counseling interventions among a sample of the general population in Palermo, Italy. Hum Vaccin Immunother. 2020;16(10):2415-2421. doi:10.1080/21645515.2020.1728157

18.

Costantino

Mazzucco

Azzolini

, et al. Influenza vaccination coverage among medical residents: an Italian multicenter survey. Hum Vaccin Immunother. 2014;10(5):1204-1210. doi:10.4161/hv.28081

19.

Dalma

Karnaki

Baka

, et al. Promotion of immunizations for health professionals in Europe: a qualitative study in seven European member states. Hosp Top. 2018;96(1):18-27. doi:10.1080/00185868.2017.1365571

20.

de Figueiredo

Simas

Karafillakis

Paterson

Larson

. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study. Lancet. 2020;396(10255):898-908. doi:10.1016/S0140-6736(20)31558-0

21.

Della Polla

Pelullo

Napolitano

Angelillo

IF.

HPV vaccine hesitancy among parents in Italy: a cross-sectional study. Hum Vaccin Immunother. 2020;16(11):2744-2751. doi:10.1080/21645515.2020.1744367

22.

Desiante

Caputi

Cipriani

, et al. Assessment of coverage and analysis of the determinants of adherence to influenza vaccination in the general practitioners of Taranto. Ann Ig. 2017;29(4):256-263. doi:10.7416/ai.2017.2157

23.

Durando

Alicino

Dini

, et al. Determinants of adherence to seasonal influenza vaccination among healthcare workers from an Italian region: results from a cross-sectional study. BMJ Open. 2016;6(5):e010779. doi:10.1136/bmjopen-2015-010779

24.

Fabiani

Volpe

Faraone

, et al. Influenza vaccine uptake in the elderly population: individual and general practitioner’s determinants in Central Italy, Lazio region, 2016-2017 season. Vaccine. 2019;37(36):5314-5322. doi:10.1016/j.vaccine.2019.07.054

25.

Gallone

Cappelli

, et al. Medical students’ attitude toward influenza vaccination: results of a survey in the University of Bari (Italy). Hum Vaccin Immunother. 2017;13(8):1937-1941. doi:10.1080/21645515.2017.1320462

26.

Giambi

Fabiani

D’Ancona

, et al. Parental vaccine hesitancy in Italy: results from a national survey. Vaccine. 2018;36(6):779-787. doi:10.1016/j.vaccine.2017.12.074

27.

Giuliani

Vescio

Donà

, et al. Perceptions of Human Papillomavirus (HPV) infection and acceptability of HPV vaccine among men attending a sexual health clinic differ according to sexual orientation. Hum Vaccin Immunother. 2016;12(6):1542-1550. doi:10.1080/21645515.2015.1115935

28.

Gualano

Bert

Voglino

, et al. Attitudes towards compulsory vaccination in Italy: results from the NAVIDAD multicentre study. Vaccine. 2018;36(23):3368-3374. doi:10.1016/j.vaccine.2018.04.029

29.

Karafillakis

Simas

Jarrett

, et al. HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe. Hum Vaccin Immunother. 2019;15(7-8):1615-1627. doi:10.1080/21645515.2018.1564436

30.

Karnaki

Baka

Petralias

, et al. Immunization related behaviour among healthcare workers in Europe: results of the HProImmune survey. Cent Eur J Public Health. 2019;27(3):204-211. doi:10.21101/cejph.a5514

31.

Keske

Mutters

Tsioutis

Ergönül

; EUCIC influenza vaccination survey team. Influenza vaccination among infection control teams: a EUCIC survey prior to COVID-19 pandemic. Vaccine. 2020;38(52):8357-8361. doi:10.1016/j.vaccine.2020.11.003

32.

Ledda

Costantino

Cuccia

Maltezou

Rapisarda

Attitudes of healthcare personnel towards vaccinations before and during the COVID-19 pandemic. Int J Environ Res Public Health. 2021;18(5):2703. doi:10.3390/ijerph18052703

33.

Lo Vecchio

Cambriglia

Fedele

, et al. Determinants of low measles vaccination coverage in children living in an endemic area. Eur J Pediatr. 2019;178(2):243-251. doi:10.1007/s00431-018-3289-5

34.

Montalti

Rallo

Guaraldi

, et al. Would parents get their children vaccinated against SARS-CoV-2? Rate and predictors of vaccine hesitancy according to a survey over 5000 families from Bologna, Italy. Vaccines. 2021;9(4):366. doi:10.3390/vaccines9040366

35.

Napolitano

Gualdieri

Santagati

Angelillo

IF.

Knowledge and attitudes toward HPV infection and vaccination among immigrants and refugees in Italy. Vaccine. 2018;36(49):7536-7541. doi:10.1016/j.vaccine.2018.10.050.

36.

Napolitano

Liguori

Angelillo

I.F.

Human papillomavirus infection and vaccination: knowledge and attitudes among young males in Italy. Hum Vaccin Immunother. 2016;12(6):1504-1510. doi:10.1080/21645515.2016.1156271

37.

Prospero

Galmozzi

Paris

, et al. Factors influencing refusing of flu vaccination among pregnant women in Italy: healthcare workers’ role. Influenza Other Respir Viruses. 2019;13(2):201-207. doi:10.1111/irv.12600

38.

Reno

Maietti

Fantini

, et al. Enhancing COVID-19 vaccines acceptance: results from a survey on vaccine hesitancy in Northern Italy. Vaccines. 2021;9(4):378. doi:10.3390/vaccines9040378

39.

Rosso

Massimi

De Vito

, et al. Knowledge and attitudes on pediatric vaccinations and intention to vaccinate in a sample of pregnant women from the City of Rome. Vaccine. 2019;37(14):1954-1963. doi:10.1016/j.vaccine.2019.02.049

40.

Santangelo

Provenzano

Firenze

Factors influencing flu vaccination in nursing students at Palermo University. J Prev Med Hyg. 2021;61(4):e563-e567. doi:10.15167/2421-4248/jpmh2020.61.4.1426

41.

Scatigna

Fabiani

Micolucci

Santilli

Mormile

Giuliani

AR.

Attitudinal variables and a possible mediating mechanism for vaccination practice in health care workers of a local hospital in L’Aquila (Italy). Hum Vaccin Immunother. 2017;13(1):198-205. doi:10.1080/21645515.2016.1225638.

42.

Vezzosi

Santagati

Angelillo

IF.

Knowledge, attitudes, and behaviors of parents towards varicella and its vaccination. BMC Infect Dis. 2017;17(1):172. doi:10.1186/s12879-017-2247-6

43.

Vimercati

Bianchi

Mansi

, et al. Influenza vaccination in health-care workers: an evaluation of an on-site vaccination strategy to increase vaccination uptake in HCWs of a South Italy Hospital. Hum Vaccin Immunother. 2019;15(12):2927-2932. doi:10.1080/21645515.2019.1625645

44.

Knudsen

Laursen

HVB

Johnsen

Bartels

Ehlers

Mainz

Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Serv Res. 2019;19(1):683. doi:10.1186/s12913-019-4482-6

45.

McNicholas

Lennox

Woodcock

Bell

Reed

JE.

Evolving quality improvement support strategies to improve plan-do-study-act cycle fidelity: a retrospective mixed-methods study. BMJ Qual Saf. 2019;28(5):356-365. doi:10.1136/bmjqs-2017-007605

46.

Taylor

McNicholas

Nicolay

Darzi

Bell

Reed

JE.

Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290-298. doi:10.1136/bmjqs-2013-001862

47.

Manyazewal

Mekonnen

Demelew

, et al. Improving immunization capacity in Ethiopia through continuous quality improvement interventions: a prospective quasi-experimental study. Infect Dis Poverty. 2018;7:119. doi:10.1186/s40249-018-0502-8

48.

Aceituno

Stanhope

Rebolledo

, et al. Using a monitoring and evaluation framework to improve study efficiency and quality during a prospective cohort study in infants receiving rotavirus vaccination in El Alto, Bolivia: the Infant Nutrition, Inflammation, and Diarrheal Illness (NIDI) study. BMC Public Health. 2017;17:911. doi:10.1186/s12889-017-4904-5

49.

Crosier

McVey

French

‘By failing to prepare you are preparing to fail’: lessons from the 2009 H1N1 ‘swine flu’ pandemic. Eur J Public Health. 2015;25(1):135-139. doi:10.1093/eurpub/cku131

50.

Signorelli

Oleari

Greco

, et al. The Italian national vaccine prevention plans, 1999/2000-2023/2025: challenges and obstacles to vaccine coverage goals. Commentary247. Ann Ist Super Sanità. 2024;60(4):247-251. doi:10.4415/ANN_23_01_04

51.

Minardi

Gallo

Possenti

, et al. Influenza vaccination uptake and prognostic factors among health professionals in Italy: results from the nationwide surveillance PASSI 2015-2018. Vaccines. 2023;11(7):1223. doi:10.3390/vaccines11071223

52.

Fabiani

Ferrante

Minardi

, et al. Comparison of rubella immunization rates in immigrant and Italian women of childbearing age: results from the Italian behavioral surveillance system PASSI (2011-2015). PLoS ONE. 2017;12(10):e0178122. doi:10.1371/journal.pone.0178122

53.

Zanobini

Lorini

Caini

, et al. Health literacy, socioeconomic status and vaccination uptake: a study on influenza vaccination in a population-based sample. Int J Environ Res Public Health. 2022;9(11):6925. doi:10.3390/ijerph19116925

54.

Contoli

Possenti

Minardi

, et al. What is the willingness to receive vaccination against COVID-19 among the elderly in Italy? Data from the PASSI d’Argento surveillance system. Front Public Health. 2021;9:736976. doi:10.3389/fpubh.2021.736976.

55.

Lorini

Del Riccio

Zanobini

, et al. Vaccination as a social practice: towards a definition of personal, community, population, and organizational vaccine literacy. BMC Public Health. 2023;23:1501. doi:10.1186/s12889-023-16437-6

56.

Costantino

Rizzo

Rosselli

, et al. Ten actions to counteract vaccine hesitancy suggested by the Italian society of hygiene, preventive medicine, and public health. Vaccines. 2022;10:1030. doi:10.3390/vaccines10071030

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