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Preplanned Studies: Willingness of Caregivers to Have Their Children Vaccinated with Pneumococcal Vaccines in the Context of an Innovative Immunization Strategy — Weifang City, Shandong Province, 2021

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  • Summary

    What is already known about this topic?

    Pneumococcal diseases (PDs) pose a serious health threat to children. Vaccination is the most cost-effective intervention to prevent PDs, but pneumococcal vaccines coverage among children is low in China.

    What is added by this report?

    This study investigated the willingness of children’s caregivers to have their children vaccinated with pneumococcal vaccines under an innovative policy to offer 1-dose of the 13-valent pneumococcal conjugate vaccines at no charge to families. The research found that 70.51% of caregivers were willing to have their infants receive pneumococcal vaccines and that reducing the cost of vaccines may increase caregivers’ willingness.

    What are the implications for public health practice?

    This is the first evaluation in China of acceptance of pneumococcal vaccines among children under a 1-dose, cost-free policy. The results provide scientific evidence for updating local and national pneumococcal immunization strategies to promote the use of the pneumococcal vaccine.

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  • Funding: Supported by Education Foundation of Peking Union Medical College and funded by Bill & Melinda Gates Foundation Donation Project (OPP1216666), and the discipline construction funds of Population Medicine from Peking Union Medical College (WH10022021145)
  • [1] Chinese Preventive Medical Association, Vaccine and Immunology Branch of Chinese Preventive Medical Association. Expert consensus on immunoprophylaxis of pneumococcal disease (2020 version). Chin J Epidemiol 2020;41(12):1945 − 79. http://dx.doi.org/10.3760/cma.j.cn112338-20201111-01322 (In Chinese). CrossRef
    [2] WHO. Immunization agenda 2030: a global strategy to leave no one behind. 2020. https://www.who.int/publications/m/item/immunization-agenda-2030-a-global-strategy-to-leave-no-one-behind. [2021-10-17].https://www.who.int/publications/m/item/immunization-agenda-2030-a-global-strategy-to-leave-no-one-behind
    [3] Lai XZ, Wahl B, Yu WZ, Xu TT, Zhang HJ, Garcia C, et al. National, regional, and provincial disease burden attributed to Streptococcus pneumoniae and Haemophilus influenzae type b in children in China: modelled estimates for 2010-17. Lancet Reg Health West Pac 2022;22:100430. http://dx.doi.org/10.1016/j.lanwpc.2022.100430CrossRef
    [4] Wang WC, Wang HQ. Status and influencing factors of vaccination with non-Expanded Program on Immunization vaccines in China. Chin J Vaccine Immun 2020;26(1):93-7. https://d.wanfangdata.com.cn/periodical/zgjhmy202001020. (In Chinese). https://d.wanfangdata.com.cn/periodical/zgjhmy202001020
    [5] Zhu L, Gao J, Bai DX. A meta-analysis of the vaccination willingness of pneumococcal vaccines in Chinese residents. Prev Med 2021;33(9):935 − 9,943. http://dx.doi.org/10.19485/j.cnki.issn2096-5087.2021.09.019 (In Chinese). CrossRef
    [6] Ikilezi G, Augusto OJ, Dieleman JL, Sherr K, Lim SS. Effect of donor funding for immunization from Gavi and other development assistance channels on vaccine coverage: evidence from 120 low and middle income recipient countries. Vaccine 2020;38(3):588 − 96. http://dx.doi.org/10.1016/j.vaccine.2019.10.057CrossRef
    [7] Wagner AL, Boulton ML, Sun XD, Mukherjee B, Huang ZY, Harmsen IA, et al. Perceptions of measles, pneumonia, and meningitis vaccines among caregivers in Shanghai, China, and the health belief model: a cross-sectional study. BMC Pediatr 2017;17(1):143. http://dx.doi.org/10.1186/s12887-017-0900-2CrossRef
    [8] Hon KL, Tsang YC, Chan LCN, Ng DKK, Miu TY, Chan JY, et al. A community-based cross-sectional immunisation survey in parents of primary school students. NPJ Prim Care Respir Med 2016;26:16011. http://dx.doi.org/10.1038/npjpcrm.2016.11CrossRef
    [9] Paterson P, Meurice F, Stanberry LR, Glismann S, Rosenthal SL, Larson HJ. Vaccine hesitancy and healthcare providers. Vaccine 2016;34(52):6700 − 6. http://dx.doi.org/10.1016/j.vaccine.2016.10.042CrossRef
    [10] Çiftci F, Şen E, Demir N, Çiftci O, Erol S, Kayacan O. Beliefs, attitudes, and activities of healthcare personnel about influenza and pneumococcal vaccines. Hum Vaccin Immunother 2018;14(1):111 − 7. http://dx.doi.org/10.1080/21645515.2017.1387703CrossRef
  • TABLE 1.  Characteristics and pneumococcal vaccination willingness among caregivers in Weifang, Shandong Province, China (n=1,085).

    CharacteristicsCategoryTotal (%)Willing
    (%)
    Unwilling
    (%)
    P
    Child genderMale569 (52.44)400 (70.30)169 (29.70)0.88
    Female516 (47.56)365 (70.74)151 (29.26)
    Family typeSingle child family455 (41.94)341 (74.95)114 (25.05)<0.01
    Multiple child family630 (58.06)424 (67.30)206 (32.70)
    Average annual household income (CNY)<50,000194 (17.88)121 (62.37)73 (37.63)<0.01
    50,000–150,000660 (60.83)466 (70.61)194 (29.39)
    ≥150,000231 (21.29)178 (77.06)53 (22.94)
    Relationship between participant and childMother679 (62.58)480 (70.69)199 (29.31)0.95
    Father394 (36.31)277 (70.30)117 (29.70)
    Grandparent12 (1.11)8 (66.67)4 (33.33)
    Education levelElementary school or below15 (1.38)8 (53.33)7 (46.67)<0.01
    Junior high school242 (22.30)155 (64.05)87 (35.95)
    High school/technical school/vocational school269 (24.79)181 (67.29)88 (32.71)
    Junior college/bachelor degree528 (48.66)396 (75.00)132 (25.00)
    Graduate degree31 (2.87)25 (80.65)6 (19.35)
    Participants’ medical education background*Yes139 (12.81)103 (74.10)36 (25.90)0.32
    No946 (87.19)662 (69.98)284 (30.02)
    Whether the pneumococcal vaccine is the COVID-19 vaccineYes or unknown333 (30.69)202 (60.66)131 (39.34)<0.01
    No752 (69.31)563 (74.87)189 (25.13)
    Perceived importance of vaccinationYes1046 (96.41)751 (71.80)295 (28.20)<0.01
    No39 (3.59)14 (35.90)25 (64.10)
    Perceived safety of vaccinationYes990 (91.24)700 (70.71)290 (29.29)0.64
    No95 (8.76)65 (68.42)30 (31.58)
    Perceived effectiveness of vaccinationYes984 (90.69)703 (71.44)281 (28.56)<0.05
    No101 (9.31)62 (61.39)39 (38.61)
    Perception that pneumonia is serious in childrenSerious1032 (95.12)740 (71.71)292 (28.29)<0.01
    General42 (3.87)17 (40.48)25 (59.52)
    Light11 (1.01)8 (72.73)3 (27.27)
    Perception that children can suffer from pneumoniaHigh597 (55.02)459 (76.88)138 (23.12)<0.01
    General330 (30.41)215 (65.15)115 (34.85)
    Low158 (14.57)91 (57.59)67 (42.41)
    Awareness of Weifang’s one-free-dose policy for PCV13Yes203 (18.71)174 (85.71)29 (14.29)<0.01
    No882 (81.29)591 (67.01)291 (32.99)
    HWs recommended pneumococcal vaccines for childrenYes153 (14.10)136 (88.89)17 (11.11)<0.01
    No932 (85.90)629 (67.49)303 (32.51)
    Trust in the vaccine information provided by HWsYes1024 (94.38)733 (71.58)291 (28.42)<0.01
    No61 (5.62)32 (52.46)29 (47.54)
    Child’s siblings received pneumococcal vaccineYes128 (20.32)121 (94.53)7 (5.47)<0.01
    No502 (79.68)303 (60.36)199 (39.64)
    * Medical education background refers to people with medicine-related training, such as medical workers, medical students, and teachers in medical schools.
    Abbreviations: PCV13=13-valent pneumococcal conjugate vaccine; HWs=Health workers.
    Download: CSV

    TABLE 2.  Logistic regression analyses of caregivers’ willingness to accept pneumococcal vaccines for their children, Weifang, Shandong Province, China.

    Independent variablesCategoryPOR (95% CI)
    Perceived importance of vaccinationNoRef
    Yes<0.013.96 (1.92–8.20)
    HWs recommended pneumococcal vaccines for childrenNoRef
    Yes<0.052.09 (1.11–3.93)
    Trust in the vaccine information provided by HWsNoRef
    Yes<0.051.92 (1.08–3.41)
    Awareness of Weifang’s one-free-dose policy for PCV13NoRef
    Yes<0.051.70 (1.01–2.87)
    Whether the pneumococcal vaccine is the COVID-19 vaccineYes or unknownRef
    No<0.011.67 (1.23–2.25)
    Average annual household income (CNY)<50,000Ref
    50,000–150,0000.141.31 (0.92–1.87)
    ≥150,000<0.011.85 (1.18–2.90)
    Perception that children can suffer from pneumoniaHighRef
    General<0.010.60 (0.44–0.83)
    Low<0.010.43 (0.29–0.63)
    Perception that pneumonia is serious in childrenSeriousRef
    General<0.010.38 (0.19–0.77)
    Light0.961.04 (0.25–4.27)
    Note: Thirteen variables were included in the logistic model: type of family, average household income per year, education level of participants, participants’ medical education background, whether the pneumococcal vaccine is the COVID-19 vaccine, perceived importance of vaccination, perception that pneumonia is serious in children, perception that children can suffer from pneumonia, awareness of Weifang’s one-free-dose policy for PCV13, HWs recommended pneumococcal vaccines for children, trust in the vaccine information provided by HWs, perceived safety of vaccination, and perceived effectiveness of vaccination. Eight variables were statistically significant.
    Abbreviations: PCV13=13-valent pneumococcal conjugate vaccine; HWs=Health workers.
    Download: CSV

    TABLE 3.  Reasons for hesitation or refusal to accept pneumococcal vaccines (n=320).

    ReasonsTotalProportion (%)
    Unfamiliar with pneumococcal vaccines24476.25
    Lack of confidence in the effectiveness of the PCV139128.44
    Worried about adverse reactions from vaccines8526.56
    My child is healthy, and he/she does not need the vaccines4413.75
    Pneumococcal vaccines are expensive3210.00
    Too busy to go to the clinic or live too far from the clinic134.06
    Children have allergies or contraindications to vaccines72.19
    Do not know where to get the PCV1310.31
    Other reasons (participants may give detailed reasons)123.75
    Note: Reasons are not mutually exclusive. Each participant can select up to three answers.
    Abbreviations: PCV13=13-valent pneumococcal conjugate vaccine; HWs=Health workers.
    Download: CSV

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Willingness of Caregivers to Have Their Children Vaccinated with Pneumococcal Vaccines in the Context of an Innovative Immunization Strategy — Weifang City, Shandong Province, 2021

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Summary

What is already known about this topic?

Pneumococcal diseases (PDs) pose a serious health threat to children. Vaccination is the most cost-effective intervention to prevent PDs, but pneumococcal vaccines coverage among children is low in China.

What is added by this report?

This study investigated the willingness of children’s caregivers to have their children vaccinated with pneumococcal vaccines under an innovative policy to offer 1-dose of the 13-valent pneumococcal conjugate vaccines at no charge to families. The research found that 70.51% of caregivers were willing to have their infants receive pneumococcal vaccines and that reducing the cost of vaccines may increase caregivers’ willingness.

What are the implications for public health practice?

This is the first evaluation in China of acceptance of pneumococcal vaccines among children under a 1-dose, cost-free policy. The results provide scientific evidence for updating local and national pneumococcal immunization strategies to promote the use of the pneumococcal vaccine.

  • 1. Division of Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China
  • 2. School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
  • 3. Weifang Medical University, Weifang City, Shandong Province, China
  • 4. Department of Respiratory and Critical Care Medicine, Affiliated Hospital of Guilin Medical University, Guilin City, Guangxi Zhuang Autonomous Region, China
  • 5. Zhejiang Center for Disease Control and Prevention, Hangzhou City, Zhejiang Province, China
  • 6. Weifang Center for Disease Control and Prevention, Weifang City, Shandong Province, China
  • Corresponding authors:

    Luzhao Feng, fengluzhao@cams.cn

    Chunping Wang, chpwang@163.com

    Weizhong Yang, yangweizhong@cams.cn

  • Funding: Supported by Education Foundation of Peking Union Medical College and funded by Bill & Melinda Gates Foundation Donation Project (OPP1216666), and the discipline construction funds of Population Medicine from Peking Union Medical College (WH10022021145)
  • doi: 10.46234/ccdcw2022.097
  • Pneumococcal diseases (PDs) pose a serious health threat to children (1). Vaccination is the most cost-effective intervention to prevent PDs (2). However, vaccination coverage of pneumococcal vaccines, which has not been introduced into the National Immunization Program (NIP) in China, is rather low among Chinese children (3). The cost of vaccines and the opinions of caregivers toward non-NIP vaccines are important factors that influence vaccination coverage (4). Exploring efficient strategies for increasing coverage of non-NIP vaccines is a crucial initiative for public health.

    To improve pneumococcal vaccination coverage and reduce the burden of PDs, starting in June 2021, the government of Weifang City (directly under the jurisdiction of Shandong Province) implemented a policy of providing 1-dose of 13-valent pneumococcal conjugate vaccines (PCV13) at no charge to families for children aged 6 months to 2 years in registered households. Although the free dose does not necessarily have to be the first dose of PCV13, due to the limited financial capacity of the government, the cost of the remaining doses in the series must be borne by caregivers as voluntary vaccination. The Weifang program is the first in the mainland of China for PCV13. Our study investigated caregivers’ willingness to vaccinate their children with pneumococcal vaccines under this one-free-dose policy and explored factors associated with acceptance.

    There are 3 PCV13 manufacturers with market authorization in China, 2 of which are domestic. PCV13 is normally given in a multi-dose series in a schedule that varies by the child’s age at the first dose. For example, 4 doses of PCV13 are recommended for full protection when starting at 3 months of age or younger, but only 1 dose is recommended when starting at 2 years of age or older. To avoid the influence of different immunization schedules for PCV13, we restricted the study population to children eligible for the full four-dose series of PCV13. Because our target population was infants younger than 3 months of age, we recruited caregivers as respondents, excluding those who were unable to determine the child’s vaccinations.

    The target sample size was determined by the formula, $ \mathrm{N}=\dfrac{{\mathrm{Z}}_{1-\mathrm{\alpha }/2}^{2}\mathrm{p}(1-\mathrm{p})}{{\mathrm{d}}^{2}} $. A previous study showed that the caregivers’ willingness to vaccinate children with pneumococcal vaccines was between 37.9% and 89.1% in China (5), which is a large range. We conservatively assumed P=50%, the allowable error at 3%, and α=0.05. To allow for attrition, we increased the sample size by 10%, yielding a target sample size of 1,174.

    The research team designed the questionnaires after discussing with project members and experts in related fields, and revised them after the pilot investigation. We obtained data on demographics, perceptions of the safety and effectiveness of vaccines, perceptions of the risk and seriousness of pneumonia, whether health workers (HWs) recommended pneumococcal vaccines, and whether caregivers trusted HWs. The questionnaires were administered by trained interviewers using portable Android devices to reduce input errors and missing values. We selected at random 30% of completed questionnaires for review each survey day.

    Face-to-face and telephone interviews were conducted. During one working day in a clinic, caregivers who met the inclusion criteria were invited to participate in the interview. If the day’s sample size target was not finished, we conducted a telephone survey of the children’s parents with consent. Due to the impact of COVID-19, some vaccination clinics were unable to enroll the target sample size. To reach the overall target sample size, we increased survey sites based on the geographical location of each vaccination clinic and the number of children it served.

    The study analyzed all data using SAS software (version 9.4, SAS Institute, Inc. Cary, NC, USA). Counts were expressed as n (%), and Chi-square tests and the Wilcoxon rank-sum test were used for comparisons. A multivariable logistic regression model was used to identify factors related to the caregivers’ willingness. We chose independent variables using stepwise regression. Statistical tests were two-tailed; P<0.05 was considered significant.

    Between July 17 and August 3, 2021, we conducted a survey in 57 vaccination clinics across 12 counties/districts. During this time, 1,195 caregivers were surveyed; 90.79% (1,085/1,195) of the questionnaires were completed and considered valid. Among the valid questionnaires, 72.35% (785/1,085) were face-to-face and the rest were via telephone. We conducted Chi-square analyses comparing caregivers’ willingness and demographics by whether the survey was face-to-face or over telephone, and found no statistically significant differences Supplementary Materials.

    Mothers, fathers, and grandparents were 62.58% (679/1,085), 36.31% (394/1,085), and 1.11% (12/1,085) of the participants. The average age of the parents was 31.26±4.88 years old. Among all participants, 70.51% (765/1,085) were willing to have their infants receive pneumococcal vaccines. Factors associated with greater willingness included perception of the importance of vaccination, having an HWs recommendation for vaccination, trust in the vaccine information provided by HWs, awareness of the PCV13 policy in Weifang, and other significant factors (Table 1).

    CharacteristicsCategoryTotal (%)Willing
    (%)
    Unwilling
    (%)
    P
    Child genderMale569 (52.44)400 (70.30)169 (29.70)0.88
    Female516 (47.56)365 (70.74)151 (29.26)
    Family typeSingle child family455 (41.94)341 (74.95)114 (25.05)<0.01
    Multiple child family630 (58.06)424 (67.30)206 (32.70)
    Average annual household income (CNY)<50,000194 (17.88)121 (62.37)73 (37.63)<0.01
    50,000–150,000660 (60.83)466 (70.61)194 (29.39)
    ≥150,000231 (21.29)178 (77.06)53 (22.94)
    Relationship between participant and childMother679 (62.58)480 (70.69)199 (29.31)0.95
    Father394 (36.31)277 (70.30)117 (29.70)
    Grandparent12 (1.11)8 (66.67)4 (33.33)
    Education levelElementary school or below15 (1.38)8 (53.33)7 (46.67)<0.01
    Junior high school242 (22.30)155 (64.05)87 (35.95)
    High school/technical school/vocational school269 (24.79)181 (67.29)88 (32.71)
    Junior college/bachelor degree528 (48.66)396 (75.00)132 (25.00)
    Graduate degree31 (2.87)25 (80.65)6 (19.35)
    Participants’ medical education background*Yes139 (12.81)103 (74.10)36 (25.90)0.32
    No946 (87.19)662 (69.98)284 (30.02)
    Whether the pneumococcal vaccine is the COVID-19 vaccineYes or unknown333 (30.69)202 (60.66)131 (39.34)<0.01
    No752 (69.31)563 (74.87)189 (25.13)
    Perceived importance of vaccinationYes1046 (96.41)751 (71.80)295 (28.20)<0.01
    No39 (3.59)14 (35.90)25 (64.10)
    Perceived safety of vaccinationYes990 (91.24)700 (70.71)290 (29.29)0.64
    No95 (8.76)65 (68.42)30 (31.58)
    Perceived effectiveness of vaccinationYes984 (90.69)703 (71.44)281 (28.56)<0.05
    No101 (9.31)62 (61.39)39 (38.61)
    Perception that pneumonia is serious in childrenSerious1032 (95.12)740 (71.71)292 (28.29)<0.01
    General42 (3.87)17 (40.48)25 (59.52)
    Light11 (1.01)8 (72.73)3 (27.27)
    Perception that children can suffer from pneumoniaHigh597 (55.02)459 (76.88)138 (23.12)<0.01
    General330 (30.41)215 (65.15)115 (34.85)
    Low158 (14.57)91 (57.59)67 (42.41)
    Awareness of Weifang’s one-free-dose policy for PCV13Yes203 (18.71)174 (85.71)29 (14.29)<0.01
    No882 (81.29)591 (67.01)291 (32.99)
    HWs recommended pneumococcal vaccines for childrenYes153 (14.10)136 (88.89)17 (11.11)<0.01
    No932 (85.90)629 (67.49)303 (32.51)
    Trust in the vaccine information provided by HWsYes1024 (94.38)733 (71.58)291 (28.42)<0.01
    No61 (5.62)32 (52.46)29 (47.54)
    Child’s siblings received pneumococcal vaccineYes128 (20.32)121 (94.53)7 (5.47)<0.01
    No502 (79.68)303 (60.36)199 (39.64)
    * Medical education background refers to people with medicine-related training, such as medical workers, medical students, and teachers in medical schools.
    Abbreviations: PCV13=13-valent pneumococcal conjugate vaccine; HWs=Health workers.

    Table 1.  Characteristics and pneumococcal vaccination willingness among caregivers in Weifang, Shandong Province, China (n=1,085).

    According to Table 2, caregivers who believed that vaccination was important (OR=3.96, 95% CI: 1.92–8.20), who received vaccination recommendations from HWs (OR=2.09, 95% CI: 1.11–3.93), and who trusted vaccine information provided by HWs (OR=1.92, 95% CI: 1.08–3.41) were more likely to have their infants vaccinated.

    Independent variablesCategoryPOR (95% CI)
    Perceived importance of vaccinationNoRef
    Yes<0.013.96 (1.92–8.20)
    HWs recommended pneumococcal vaccines for childrenNoRef
    Yes<0.052.09 (1.11–3.93)
    Trust in the vaccine information provided by HWsNoRef
    Yes<0.051.92 (1.08–3.41)
    Awareness of Weifang’s one-free-dose policy for PCV13NoRef
    Yes<0.051.70 (1.01–2.87)
    Whether the pneumococcal vaccine is the COVID-19 vaccineYes or unknownRef
    No<0.011.67 (1.23–2.25)
    Average annual household income (CNY)<50,000Ref
    50,000–150,0000.141.31 (0.92–1.87)
    ≥150,000<0.011.85 (1.18–2.90)
    Perception that children can suffer from pneumoniaHighRef
    General<0.010.60 (0.44–0.83)
    Low<0.010.43 (0.29–0.63)
    Perception that pneumonia is serious in childrenSeriousRef
    General<0.010.38 (0.19–0.77)
    Light0.961.04 (0.25–4.27)
    Note: Thirteen variables were included in the logistic model: type of family, average household income per year, education level of participants, participants’ medical education background, whether the pneumococcal vaccine is the COVID-19 vaccine, perceived importance of vaccination, perception that pneumonia is serious in children, perception that children can suffer from pneumonia, awareness of Weifang’s one-free-dose policy for PCV13, HWs recommended pneumococcal vaccines for children, trust in the vaccine information provided by HWs, perceived safety of vaccination, and perceived effectiveness of vaccination. Eight variables were statistically significant.
    Abbreviations: PCV13=13-valent pneumococcal conjugate vaccine; HWs=Health workers.

    Table 2.  Logistic regression analyses of caregivers’ willingness to accept pneumococcal vaccines for their children, Weifang, Shandong Province, China.

    Table 3 shows factors related to hesitancy or refusal to accept pneumococcal vaccines. The top three factors were being unfamiliar with pneumococcal vaccines, lacking confidence in the effectiveness of pneumococcal vaccines, and worrying about adverse reactions.

    ReasonsTotalProportion (%)
    Unfamiliar with pneumococcal vaccines24476.25
    Lack of confidence in the effectiveness of the PCV139128.44
    Worried about adverse reactions from vaccines8526.56
    My child is healthy, and he/she does not need the vaccines4413.75
    Pneumococcal vaccines are expensive3210.00
    Too busy to go to the clinic or live too far from the clinic134.06
    Children have allergies or contraindications to vaccines72.19
    Do not know where to get the PCV1310.31
    Other reasons (participants may give detailed reasons)123.75
    Note: Reasons are not mutually exclusive. Each participant can select up to three answers.
    Abbreviations: PCV13=13-valent pneumococcal conjugate vaccine; HWs=Health workers.

    Table 3.  Reasons for hesitation or refusal to accept pneumococcal vaccines (n=320).

    • This study found that 70.51% of caregivers were willing for their children to get pneumococcal vaccines under the one-free-dose policy in Weifang. The acceptance rate for pneumococcal vaccines in our study was lower than that found in an online survey conducted in 2020 and was higher than that found in field surveys in Shanghai and Guangzhou (5).

      We speculated that the relatively higher willingness in Weifang may be related to the fact that caregivers have gained much in-depth health knowledge through various media during the COVID-19 pandemic. Additionally, immunization strategies may change vaccination willingness. Vaccine support from Gavi and other nonprofit organizations has significantly increased the coverage of pneumococcal vaccines in recipient countries (6). We also found that the willingness to accept pneumococcal vaccines was associated with the awareness of the one-free-dose policy in Weifang. The pneumococcal vaccination willingness among caregivers who knew about the one-free-dose immunization policy was 1.70 times higher than those who did not know.

      Caregivers’ perceptions of the risk of pneumonia and the safety and effectiveness of vaccines are important factors related to pneumococcal vaccination willingness (7). Hon et al. surveyed 3,485 parents in Hong Kong, China and found that pneumococcal vaccination of children was related to the awareness of parents regarding the seriousness of PDs and the belief that PCV can effectively prevent PDs (8). In our study, 95.12% of the participants perceived pneumonia as a serious threat to children’s health, and most of the participants trusted in the safety and effectiveness of vaccines. Notably, many participants lacked knowledge about pneumococcal vaccines. For example, 30.69% of the participants misidentified the pneumococcal vaccine as the COVID-19 vaccine. In addition, the primary reason for hesitancy or refusal to vaccinate against PDs was being unfamiliar with pneumococcal vaccines. Health education for caregivers is extremely important for the public health sector.

      Vaccine recommendations from HWs significantly increase acceptance of vaccines and improve vaccination willingness among the public (9). The opinions and attitudes of HWs toward vaccines are likely to influence their vaccine recommendation behavior (10). In our survey, 94.38% of the participants reported that they trusted the vaccine information provided by HWs, and the willingness of these participants was significantly higher than those who did not trust the vaccine information provided by HWs. Unfortunately, a minority of the participants had received a pneumococcal recommendation from HWs to vaccinate against PDs. To minimize the incidence of PDs in high-risk groups (such as infants and the elderly), HWs should be encouraged to take positive action to improve pneumococcal vaccination coverage.

      In summary, reducing the burden of out-of-pocket costs for PCV may increase the willingness of caregivers to have their children vaccinated. Education of caregivers about vaccination should be reinforced, and the importance of HWs promotion of vaccination should be emphasized.

      To our knowledge, this is the first study in China to investigate caregivers’ willingness to vaccinate their children in the context of an immunization policy that provides one-free-dose of PCV13 per child. The results provide scientific evidence for updating local and national pneumococcal immunization strategies. Our study has limitations. We did not ask participants whether they were willing to have their infants complete the vaccination series if they must bear the cost of the remaining doses, and we did not explore measures to promote completion of the full-course, four-dose PCV13 series. These limitations will be addressed in future research.

    • All the volunteers; Weifang Health Commission, Weifang Municipal Center for Disease Prevention and Control colleagues and vaccination clinic doctors; and Dr. Heng Du, Dr. Jiansheng Wang, and Prof. Xiangbin Wang.

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