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Focus group transcripts for Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups


Gonzalez-Block, Miguel Ángel et al. (2021), Focus group transcripts for Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups, Dryad, Dataset,


Influenza vaccination coverage in countries of Latin America is low among priority risk groups, ranging from 5 to 75% among older people. This paper aims to describe and analyze the determinants of influenza vaccination hesitancy through the lens of the 3C model of confidence, complacency and convenience among middle-class, urban risk group populations in Brazil, Chile, Paraguay, Peru, Uruguay, countries in South America with contrasting vaccination coverage. Focus groups were conducted among four risk groups: pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥ 60 years in samples of urban residents.  Adults with risk factors expressed the most detailed perceptions about confidence in the vaccine. A wide range of perceptions regarding complacency were expressed across risk groups and countries, with pregnant women and mothers showing greater concerns while convenience had a narrower and generally more positive range of perceptions. Participants from Chile and Paraguay expressed the most contrasts regarding confidence and complacency. Information and communication strategies need to be tailored for risk groups while confidence and complacency should be addressed in synergy. 


The protocol was reviewed by authorized ethics committees within each of the study countries, as follows: Brazil, Comissão Nacional de Ética em Pesquisa, 05215918.6.0000.5347. Chile: Comité de Ética de Investigación en Seres, Universidad de Chile, Facultad de Medicina, 191-2018. Paraguay: Comité de ética en Investigación, Laboratorio Central de Salud Pública, 106/2019. Peru: Comité de Ética de Investigación Prisma, CE1651.18. Uruguay: Comité de Ética en Investigación, Instituto Nacional de Salud Pública, 1580.

The study design is multi-center and qualitative, contrasting knowledge, attitudes and practices through focus group technique with homogeneous members of four risk groups. Focus group methodology was chosen over other techniques to address the qualitative aspects of vaccine hesitancy given its capacity to obtain a greater amount of information in a shorter time elicited both through directed queues and the interaction between participants. [14] Furthermore, focus groups would enable us to obtain a first repertoire of perceptions on the basis of which to later address the hesitancy through more structured instruments. Interaction between persons sharing risk group characteristics would elicit the widest possible range of views based on knowledge, beliefs and practices regarding influenza vaccine confidence, complacency and convenience.

Focus groups were evenly distributed in one or two large cities within each country as follows Brazil: Porto Alegre (in the state of Rio Grande do Sul); Chile: Santiago and Valparaíso; Perú: Arequipa and Lima; Paraguay: Asunción and Ciudad del Este, and Uruguay: Montevideo and Salto (Table 1). Participants across the four risk groups lived in lower-middle class neighborhoods. A representative survey of health facility clients in the same neighborhoods undertaken as a part of the same research project to explore quantitative determinants of vaccine hesitancy showed that between 26.9 and 38.8% of elderly adults and adults with risk factors, respectively, had up to primary education, as against pregnant women and mothers of children, among whom only between 8.1 and 9.3% had such lower education levels. Participants from Paraguay and Uruguay tended to have lower education levels across risk groups when compared to participants from the other countries [15].

Focus groups were piloted and initiated in Peru in October 2018 and followed up in the four other countries between March and July of 2019, as soon as ethics committee authorizations allowed, and aiming to hold them as close as possible to influenza immunization campaigns. Table 1 describes the focus group recruitment strategy and characteristics. Individuals with homogeneous characteristics were recruited based on having the attributes of each of the following risk-groups: adults above 60 years of age (OA), adults with risk factors (ARF), pregnant women (PW) and mothers of children under 6 years of age (MC). Focus groups had between 6 and 10 participants with an average of 8, recruited upon leaving health facilities in the case of Brazil, Paraguay and Peru. In Chile, participants were recruited based on a sample frame developed for research purposes and registering risk group attributes and socioeconomic characteristics. In Uruguay, recruitment was based on a Facebook call, filtering for risk group and health service use characteristics. Heterogeneity within focus groups was sought with respect to the vaccination decision (accepted and declined) in order to understand in-depth, the reasons and influences in both cases, as well as the obstacles and facilitators that led to their choice. Focus groups were undertaken in Spanish or Portuguese for the case of Brazil. All participants spoke Spanish or Portuguese and no translation was required. Focus groups were moderated in all cases by an expert focus group researcher, supported by an observer. Focus groups were held in meeting rooms or open spaces within or next to health facilities in Brazil, Paraguay (one focus group) and Peru, and in research meeting rooms or a hotel meeting room in Chile, Paraguay (three focus groups) and Uruguay.

A discussion guide was developed and organized into knowledge, attitudes and practices sections including each the discussion of vaccine confidence, influenza complacency and vaccine convenience. (The guide is available as a supplementary file). Within each section. Focus group sessions were audio-recorded after verbal informed consent was obtained from participants and information was transcribed verbatim. A first code list was developed by two of the authors (BP and MAGB) based on the theoretical framework and the pilot study focus group data from Peru. A coding manual was provided to researchers within countries (YC, PC, AFL, LB, DRK, BR and MR). Codes were inductively refined and detailed by country-level researchers based on focus group data. Detailed codes were reviewed by BP to arrive to a final set of codes for each country. Country data codification was reviewed by BP, DRK, AFL and disagreements involving the allocation of statement to the categories of confidence or complacency were resolved by consensus. Information was encoded with the support of the Atlas-ti v.8 software. Qualitative content analysis was carried out on thematic units of analysis based on the 3 Cs model categories by each of the country researchers. The main focus of analysis were risk groups, followed by cross-risk group analysis. Country case studies were produced by country-level researchers and reviewed by BP and MAGB. Final interpretation was based on comparing country case studies.

Usage Notes

The dataset provides full focus group transcripts


Sanofi Pasteur, Award: FLU-90