Abstracts

Introduction

Vaccination has become a critical tool for reducing the incidence of many infectious diseases and associated mortality ¹1. Remy V, Zollner Y, Heckmann U. Vaccination: the cornerstone of an efficient healthcare system. J Mark Access Health Policy 2015; 3:27041.. Its health benefits translate into positive economic outcomes for health systems and society. Indeed, access to vaccines should be an economic development strategy for countries. However, vaccines are often undervalued or underused for a variety of reasons ¹1. Remy V, Zollner Y, Heckmann U. Vaccination: the cornerstone of an efficient healthcare system. J Mark Access Health Policy 2015; 3:27041.. Low vaccination coverage remains a public health problem in many regions, including Latin America ²2. Andrus JK, Bandyopadhyay AS, Danovaro-Holliday MC, Dietz V, Domingues C, Peter FJ, et al. The past, present, and future of immunization in the Americas. Rev Panam Salud Pública 2017; 41:e121.^,33. Lindstrand A, Cherian T, Chang-Blanc D, Feikin D, O'Brien KL. The world of immunization: achievements, challenges, and strategic vision for the next decade. J Infect Dis 2021; 224 Suppl 4:S452-67.. Achieving effective vaccination coverage depends on several factors, including those related to the quality of health services, individual and community practices, and political decision-making ⁴4. Butler R, MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Diagnosing the determinants of vaccine hesitancy in specific subgroups: the Guide to Tailoring Immunization Programmes (TIP). Vaccine 2015; 33:4176-9.^,55. Colome-Hidalgo M, Donado Campos J, Gil de Miguel A. Monitoring inequality changes in full immunization coverage in infants in Latin America and the Caribbean. Rev Panam Salud Pública 2020; 44:e56.. Increasingly higher coverage rates are needed to control target diseases, while both the complexity of vaccine logistics and costs have increased ⁶6. Scobie HM, Edelstein M, Nicol E, Morice A, Rahimi N, MacDonald NE, et al. Improving the quality and use of immunization and surveillance data: summary report of the Working Group of the Strategic Advisory Group of Experts on Immunization. Vaccine 2020; 38:7183-97.. Although progress has been made in achieving coverage objectives in Latin America, rates are still below the levels set by the Pan American Health Organization (PAHO), with significant socioeconomic disparities in coverage rates, which vary widely between and within countries ⁵5. Colome-Hidalgo M, Donado Campos J, Gil de Miguel A. Monitoring inequality changes in full immunization coverage in infants in Latin America and the Caribbean. Rev Panam Salud Pública 2020; 44:e56.^,66. Scobie HM, Edelstein M, Nicol E, Morice A, Rahimi N, MacDonald NE, et al. Improving the quality and use of immunization and surveillance data: summary report of the Working Group of the Strategic Advisory Group of Experts on Immunization. Vaccine 2020; 38:7183-97..

Vaccine refusal is a global challenge, threatening the acceptance of vaccines and the objectives of vaccination programs ⁷7. Gonzalez-Block MA, Arroyo-Laguna J, Rodríguez-Zea B, Pelcastre-Villafuerte BE, Gutiérrez-Calderón E, Díaz-Portillo SP, et al. The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru. Hum Vaccin Immunother 2021; 17:465-74.^,88. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,99. Brown AL, Sperandio M, Turssi CP, Leite RMA, Berton VF, Succi RM, et al. Vaccine confidence and hesitancy in Brazil. Cad Saúde Pública 2018; 34:e00011618.^,1010. Schuster M, Eskola J, Duclos P; SAGE Working Group on Vaccine Hesitancy. Review of vaccine hesitancy: rationale, remit and methods. Vaccine 2015; 33:4157-60.. In 2011, the World Health Organization’s (WHO) Strategic Advisory Group of Experts on Immunization (SAGE) established a working group to address “vaccine hesitancy”, defined as a “delay in accepting vaccination or refusal of vaccines despite the availability of vaccination services” ⁷7. Gonzalez-Block MA, Arroyo-Laguna J, Rodríguez-Zea B, Pelcastre-Villafuerte BE, Gutiérrez-Calderón E, Díaz-Portillo SP, et al. The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru. Hum Vaccin Immunother 2021; 17:465-74. (p. 1). This concept posits a continuum between those who accept all vaccines without hesitation or concern and those who reject them outright, identifying individuals or groups between these two extremes as “hesitant”. More recently, a working group established by the WHO to measure the behavioral and social drivers of vaccination defined vaccine hesitancy as a motivational state of being conflicted or opposed to vaccination ¹¹11. World Health Organization. Behavioural and social drivers of vaccination: tools and practical guidance for achieving high uptake. Geneva: World Health Organization; 2022.. The concept has become a widely recognized term and has gained traction in vaccine discussions and research over the past decade, particularly in the context of COVID-19 ¹²12. Larson HJ. Defining and measuring vaccine hesitancy. Nat Hum Behav 2022; 6:1609-10.. However, criticism has been raised, including concerns about the operationalization of vaccine hesitancy in research ¹²12. Larson HJ. Defining and measuring vaccine hesitancy. Nat Hum Behav 2022; 6:1609-10.^,1313. Peretti-Watel P, Larson HJ, Ward JK, Schulz WS, Verger P. Vaccine hesitancy: clarifying a theoretical framework for an ambiguous notion. PLoS Curr 2015; 7:ecurrents.outbreaks.6844c80ff9f5b273f34c91f71b7fc289.
ecurrents.outbreaks.6844c80ff9f5b273f34c... , its oversimplification of vaccine decision-making, and the potential for stigmatization of hesitant individuals ¹⁴14. Reich JA. Calling the shots: why parents reject vaccines. New York: NYU Press; 2016.. There are also warnings about the use of frameworks designed for the Global North in the Global South and the importance of considering regional differences in beliefs and behaviors for effective public health research ¹⁵15. Matos CCSA, Gonçalves BA, Couto MT. Vaccine hesitancy in the global south: towards a critical perspective on global health. Glob Public Health 2021; 17:1087-98..

Vaccine hesitancy does not necessarily equate to low coverage, but lack of confidence in vaccination has been linked to low vaccine uptake and a subsequent increase in morbidity and mortality from vaccine-preventable diseases. Inequalities in routine immunization in Latin America have been exacerbated by the effects of the COVID-19 pandemic on vulnerable populations and by misconceptions about vaccines spread by anti-vaccine movements ¹⁶16. Ávila-Agüero ML, Ospina-Henao S, Pirez MC, Gentile A, Araya S, Brea J, et al. Latin American forum on immunization services during the COVID-19 pandemic. Expert Rev Vaccines 2021; 20:231-4.. To improve vaccination coverage in Latin America, it is important to identify the factors that act as barriers to vaccine uptake. Regarding access to vaccines, the implementation of vaccination policies in the region faces several challenges to resolve inequalities in vaccination coverage, such as lack of adequate financial support and common regulations among countries, problems in the introduction of new vaccines, deficiencies in the training of health personnel and low awareness of vaccine-preventable diseases among the general population ¹⁷17. Guzman-Holst A, DeAntonio R, Prado-Cohrs D, Juliao P. Barriers to vaccination in Latin America: a systematic literature review. Vaccine 2020; 38:470-81..

Most primary studies and reviews report findings from high-income countries, and research on other regions is needed to provide contextual information on perceptions and attitudes towards vaccination ¹⁸18. Dube E, Vivion M, MacDonald NE. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: influence, impact and implications. Expert Rev Vaccines 2015; 14:99-117.^,1919. Jarrett C, Wilson R, O'Leary M, Eckersberger E, Larson HJ; SAGE Working Group on Vaccine Hesitancy. Strategies for addressing vaccine hesitancy: a systematic review. Vaccine 2015; 33:4180-90.. It has been highlighted that some factors underlying vaccine mistrust - such as the appeal of conspiracy theories - can only be described using qualitative methods ²⁰20. Munoz FM, Eckert LO, Katz MA, Lambach P, Ortiz JR, Bauwens J, et al. Key terms for the assessment of the safety of vaccines in pregnancy: results of a global consultative process to initiate harmonization of adverse event definitions. Vaccine 2015; 33:6441-52.. Qualitative studies have also described contextual and complex factors that influence decision-making processes ²¹21. Wang E, Clymer J, Davis-Hayes C, Buttenheim A. Nonmedical exemptions from school immunization requirements: a systematic review. Am J Public Health 2014; 104:e62-84.^,2222. Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust. Pediatrics 2006; 117:1532-41.^,2323. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine 2014; 32:2150-9.^,2424. Cobos Munoz D, Monzon Llamas L, Bosch-Capblanch X. Exposing concerns about vaccination in low- and middle-income countries: a systematic review. Int J Public Health 2015; 60:767-80.. This review aimed to describe different barriers and facilitators to vaccination in Latin America by synthetizing qualitative evidence.

Methods

This systematic review was conducted according to the Enhancing Transparency of Reporting the Synthesis of Qualitative Research (ENTREQ) framework ²⁵25. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol 2012; 12:181.. Comprehensive search strategies were used to identify all available studies. This work included qualitative studies that used focus group discussions, interviews, direct observation, case studies, ethnography, and action research published in English, Spanish and Portuguese. The study populations were composed of adults, parents (those who raise or care for a child or play the role of guardian), adolescents (10-19 years of age) and health professionals (physicians, nurses, vaccinators). The outcomes assessed were knowledge (information about vaccination) and attitudes (opinions about vaccination involving a related act or its omission). The studies evaluated were conducted in countries in Latin America, including Puerto Rico. Studies conducted in Latino communities in countries outside Latin America and studies that used surveys and questionnaires were excluded.

Data sources and search

The following electronic databases were searched: PubMed, CENTRAL, Scopus, LILACS, SciELO, and CINAHL. The electronic search was conducted in January 2022. The terms used were related to knowledge, attitudes and practices regarding vaccination among participants in Latin America. No date restrictions were imposed on the search strategy (Supplementary Material: https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00165023_6423.pdf). Two authors (J.R. and N.I.) screened the titles and abstracts of the search records using Covidence (https://www.covidence.org/) and a screening guide. These two authors identified potentially eligible studies and retrieved the full text of selected records. Then, three authors (J.R., N.I., and M.B.) independently screened all full texts for eligibility and resolved discrepancies by discussion and consensus. No studies were excluded based on quality. The following characteristics were extracted: year of publication, country, population, number of participants, data collection, methodology, analysis, and research questions. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart with a summary of the records searched and selected was generated (Figure 1).

Data analysis

Thematic synthesis was used as described by Thomas & Harden ²⁶26. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008; 8:45.. The text under the results/findings sections of the included studies was imported into Atlas.Ti software (http://atlasti.com/). Two researchers (J.R. and N.I.) performed line-by-line coding, conceptualized the data and inductively identified concepts. To assess coding concordance, reconcile discrepancies and validate codebooks, two researchers independently coded four studies. Inter-coder agreement was assessed using Cohen’s kappa, with a kappa ≥ 0.80 widely accepted as demonstrating high coding concordance and semantic reliability. For subsequent articles, the text was coded into existing concepts, and a new concept was created when needed. Similar concepts were grouped into themes. To ensure that coding captured all relevant issues and reflected the primary data, researcher triangulation was used, guaranteeing that codes captured relevant data. Two researchers (J.P.A. and M.B.) reviewed the preliminary themes and discussed themes with the first two researchers.

Results

Characteristics of the included studies

Searches were run conducted in January 2022. It yielded 8,107 results, and after screening titles, abstracts and full texts, 56 articles published from 2007 to January 2022 were included (Figure 1). Box 1 provides a summary description of the included articles. Most studies were based on individual interviews or focus groups. The number of study participants ranged from 7 to 362. The main vaccines discussed by the included studies were the HPV vaccine (n = 15), childhood vaccines (n = 11), and influenza (n = 8) and maternal vaccines (n = 7). Regarding populations included in the studies, the most prominent were parents of children at vaccination age (n = 23), health professionals (n = 11) and pregnant women (n = 9). The two countries with the most studies were Brazil (n = 22) and Peru (n = 13).

Facilitators

The perceived benefit of vaccines

Vaccination was widely recognized as an effective strategy for preventing contagious diseases at the individual and collective levels ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,2727. Wong MCS, Wong ELY, Huang J, Cheung AWL, Law K, Chong MKC, et al. Acceptance of the COVID-19 vaccine based on the health belief model: a population-based survey in Hong Kong. Vaccine 2021; 39:1148-56.^,2828. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,2929. Santana BMG, Galindo YA, Peraza AMC, Chacón DP, Chacón MC, Valdés CA. Culture of health in family members of children about vaccination. Polyclinic "5 de Septiembre", January-June 2015. Rev Cuba Med Trop 2019; 71:e394.^,3030. Piñeros M, Wiesner C, Cortés C, Trujillo LM. HPV vaccine introduction at the local level in a developing country: attitudes and criteria among key actors. Cad Saúde Pública 2010; 26:900-8.^,3131. Pereira BFB, Martins MAS, Barbosa TLA, Silva CSO, Gomes LMX. Reasons why pregnant women did not vaccinate against influenza A H1N1. Ciênc Saúde Colet 2013; 18:1745-52.^,3232. Oliveira ACS, Silva GF, Souza JLAC, Maia SMA. Imunização contra influenza em colaboradores de um centro universitário. Enfermagem Brasil 2019; 18:721-6.^,3333. Morais A, Quirino M. Prática de imunização da criança prematura. Ciênc Cuid Saúde 2010; 9:350-7.^,3434. Melo MCP, Santos MM, Mendes RNC, Sales JRP, Silva RM. Perception of adolescents on immunization in a public school in Petrolina - PE. REME Rev Min Enferm 2013; 17:374-80.^,3535. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6.^,3636. Gonçalves S, Machado M. Opinion of a group of caretakers concerning the basic immunization. Rev Rene 2008; 9:45-51.^,3737. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,3838. Bingham A, Drake JK, LaMontagne DS. Sociocultural issues in the introduction of human papillomavirus vaccine in low-resource settings. Arch Pediatr Adolesc Med 2009; 163:455-61.^,3939. Arams R, Weinstock RE, Muresianu ES, O'Callaghan S, Tubridy E, Maita YT, et al. In the name of prevention: maternal perspectives on school-based HPV vaccination in rural southern Chile. Adolesc Health Med Ther 2021; 12:27-36.^,4040. Burghouts J, Del Nogal B, Uriepero A, Hermans PWM, de Waard JH, Verhagen LM. Childhood vaccine acceptance and refusal among Warao Amerindian caregivers in Venezuela: a qualitative approach. PLoS One 2017; 12:e0170227.^,4141. Figueiredo GLA, Pina JC, Tonete VLP, Lima RAG, Mello DF. Experiences of families in the immunization of Brazilian children under two years old. Rev Latinoam Enferm 2011; 19:598-605.^,4242. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14.^,4343. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por casais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.^,4444. Simas C, Paterson P, Lees S, Larson HJ. "From my phone, I could rule the world": critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil. Vaccine 2021; 39:4700-4.^,4545. Pérez-Guerra CL, Rodríguez-Acosta RL, Soto-Gómez E, Zielinski-Gutierrez E, Peña-Orellana M, Santiago LM, et al. Assessing the interest to participate in a dengue vaccine efficacy trial among residents of Puerto Rico. Hum Vaccin Immunother 2012; 8:905-15., and several participants reported perceiving vaccination as important to public health because it protected children and helped them avoid disease later in life ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,2929. Santana BMG, Galindo YA, Peraza AMC, Chacón DP, Chacón MC, Valdés CA. Culture of health in family members of children about vaccination. Polyclinic "5 de Septiembre", January-June 2015. Rev Cuba Med Trop 2019; 71:e394.^,3030. Piñeros M, Wiesner C, Cortés C, Trujillo LM. HPV vaccine introduction at the local level in a developing country: attitudes and criteria among key actors. Cad Saúde Pública 2010; 26:900-8.^,3636. Gonçalves S, Machado M. Opinion of a group of caretakers concerning the basic immunization. Rev Rene 2008; 9:45-51.^,3737. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,3838. Bingham A, Drake JK, LaMontagne DS. Sociocultural issues in the introduction of human papillomavirus vaccine in low-resource settings. Arch Pediatr Adolesc Med 2009; 163:455-61.^,3939. Arams R, Weinstock RE, Muresianu ES, O'Callaghan S, Tubridy E, Maita YT, et al. In the name of prevention: maternal perspectives on school-based HPV vaccination in rural southern Chile. Adolesc Health Med Ther 2021; 12:27-36.^,4040. Burghouts J, Del Nogal B, Uriepero A, Hermans PWM, de Waard JH, Verhagen LM. Childhood vaccine acceptance and refusal among Warao Amerindian caregivers in Venezuela: a qualitative approach. PLoS One 2017; 12:e0170227.^,4141. Figueiredo GLA, Pina JC, Tonete VLP, Lima RAG, Mello DF. Experiences of families in the immunization of Brazilian children under two years old. Rev Latinoam Enferm 2011; 19:598-605.^,4242. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14.^,4343. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por casais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.^,4444. Simas C, Paterson P, Lees S, Larson HJ. "From my phone, I could rule the world": critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil. Vaccine 2021; 39:4700-4.^,4646. Silva MRB, Oliveira RB, Silva HCD, Medeiros CS, Cunha AL, Messias CM. Imunizaçäo: o conhecimento e práticas dos profissionais de enfermagem na sala de vacina. Nursing 2020; 23:3533-6.. Some participants stated that vaccines could cure diseases ³⁸38. Bingham A, Drake JK, LaMontagne DS. Sociocultural issues in the introduction of human papillomavirus vaccine in low-resource settings. Arch Pediatr Adolesc Med 2009; 163:455-61.. Vaccination were described as an expression of good parenting ⁴²42. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14., a value ⁴³43. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por casais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.^,4444. Simas C, Paterson P, Lees S, Larson HJ. "From my phone, I could rule the world": critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil. Vaccine 2021; 39:4700-4. and a requirement for access to important benefits, such as admission to school ³⁵35. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6.^,4545. Pérez-Guerra CL, Rodríguez-Acosta RL, Soto-Gómez E, Zielinski-Gutierrez E, Peña-Orellana M, Santiago LM, et al. Assessing the interest to participate in a dengue vaccine efficacy trial among residents of Puerto Rico. Hum Vaccin Immunother 2012; 8:905-15. or the labor market ⁴⁷47. Duarte DC, Viegas S, Lanza FM, Oliveira VC. Vaccination as a scheduled demand: a day in the life of users. Rev Bras Enferm 2020; 73:e20180451. and inclusion in social welfare programs ⁴⁸48. Santos L, Barreto C, Silva F, Silva K. Percepção das mães quanto à importância da imunização infantil. Rev Rene 2011; 12:621-6.. The decision to vaccinate was seen as an act of love, a responsibility ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,4343. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por casais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.^,4444. Simas C, Paterson P, Lees S, Larson HJ. "From my phone, I could rule the world": critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil. Vaccine 2021; 39:4700-4.. Brazilian mothers believed that the immune system of premature babies was weaker and more susceptible to infection ³³33. Morais A, Quirino M. Prática de imunização da criança prematura. Ciênc Cuid Saúde 2010; 9:350-7..

“We have to prevent diseases; we have to get vaccinated. They say that there was no immunisation in the past, and people got childhood paralysis, problems with the legs, arms. Nowadays, vaccines are here to prevent these kinds of things. There is yellow fever, flu” (Brazilian mother) ⁴¹ (p. 601).

Acceptance of health care provider recommendations

Although many participants expressed concerns about the safety of vaccines, recommendations from health care providers were generally accepted ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,4949. Marbán-Castro E, Villén-Gonzalvo A, Enguita-Fernández C, Romero-Acosta KC, Marín-Cos A, Arrieta GJ, et al. Acceptability of a hypothetical Zika vaccine among women from Colombia and Spain exposed to ZIKV: a qualitative study. Vaccines (Basel) 2020; 8:580.^,5050. Handy LK, Maroudi S, Powell M, Nfila B, Moser C, Japa I, et al. The impact of access to immunization information on vaccine acceptance in three countries. PLoS One 2017; 12:e0180759.^,5151. Ve´liz L, Campos C, Vega P. Conocimiento y actitudes de los padres en relacio´n a la vacunacio´n de sus hijos. Rev Chilena Infectol 2016; 33:30-7.^,5252. Simas C, Larson HJ, Paterson P. "Saint Google, now we have information!": a qualitative study on narratives of trust and attitudes towards maternal vaccination in Mexico City and Toluca. BMC Public Health 2021; 21:1170.. Almost all participants reported seeking health information from hospitals or health center campaigns ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,2929. Santana BMG, Galindo YA, Peraza AMC, Chacón DP, Chacón MC, Valdés CA. Culture of health in family members of children about vaccination. Polyclinic "5 de Septiembre", January-June 2015. Rev Cuba Med Trop 2019; 71:e394.^,3636. Gonçalves S, Machado M. Opinion of a group of caretakers concerning the basic immunization. Rev Rene 2008; 9:45-51.^,4444. Simas C, Paterson P, Lees S, Larson HJ. "From my phone, I could rule the world": critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil. Vaccine 2021; 39:4700-4.^,5353. Rees HD, Lombardo AR, Tangoren CG, Meyers SJ, Muppala VR, Niccolai LM. Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in Leon, Nicaragua. PeerJ 2017; 5:e3871., and women were accustomed to requesting additional information and searching for evidence on the internet ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,3131. Pereira BFB, Martins MAS, Barbosa TLA, Silva CSO, Gomes LMX. Reasons why pregnant women did not vaccinate against influenza A H1N1. Ciênc Saúde Colet 2013; 18:1745-52.^,3939. Arams R, Weinstock RE, Muresianu ES, O'Callaghan S, Tubridy E, Maita YT, et al. In the name of prevention: maternal perspectives on school-based HPV vaccination in rural southern Chile. Adolesc Health Med Ther 2021; 12:27-36.^,5454. Carcelen AC, Vilajeliu A, Malik F, Gilman RH, Omer S. Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru. Vaccine 2021; 39 Suppl 2:B27-33.^,5555. Barbieri CL, Couto MT. Decision-making on childhood vaccination by highly educated parents. Rev Saúde Pública 2015; 49:18.. In Brazil, vaccination cards used by parents included basic information on vaccines and schedules ⁴¹41. Figueiredo GLA, Pina JC, Tonete VLP, Lima RAG, Mello DF. Experiences of families in the immunization of Brazilian children under two years old. Rev Latinoam Enferm 2011; 19:598-605..

“I get vaccinated with all the [vaccines] the doctor tells me because she knows more and says it for the wellness of you and your baby. Me, [the recommendations] I mostly follow is what the doctors tell me” (pregnant woman from Peru) ⁵⁴54. Carcelen AC, Vilajeliu A, Malik F, Gilman RH, Omer S. Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru. Vaccine 2021; 39 Suppl 2:B27-33. (p. 830).

Positive experiences and support from significant others

Peer reports, positive experiences of other pregnant women who had been vaccinated ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903. and simply following the family tradition of vaccination were the driving forces behind participants’ decisions to get vaccinated ⁴³43. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por casais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.. In addition, participants highlighted the positive aspects and convenience of using the vaccination card ⁴¹41. Figueiredo GLA, Pina JC, Tonete VLP, Lima RAG, Mello DF. Experiences of families in the immunization of Brazilian children under two years old. Rev Latinoam Enferm 2011; 19:598-605. and their satisfaction with the condition of health facilities or vaccination centers ⁵⁶56. Duarte DC, Viegas SMF, Augusto TFS, Oliveira VC, Martins JRT, Tholl AD. Organizational aspects and a schedule for access to vaccination from users' perspective. Texto & Contexto Enferm 2021; 30:e20190101. as reasons for adherence to schedules.

“Hygiene is a very serious thing, so you have to check these details, because this gives you confidence. So, if you see a disorganised and dirty place can be off-putting, you won’t take your child there. I usually ask to see the expiration date of the vaccines” (Brazilian woman) ⁵⁶56. Duarte DC, Viegas SMF, Augusto TFS, Oliveira VC, Martins JRT, Tholl AD. Organizational aspects and a schedule for access to vaccination from users' perspective. Texto & Contexto Enferm 2021; 30:e20190101. (p. 6).

Pregnant women identified themselves as the main decision-makers in terms of vaccination, but discussed the matter with their partners, mothers, other family members, female friends and health professionals ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,4040. Burghouts J, Del Nogal B, Uriepero A, Hermans PWM, de Waard JH, Verhagen LM. Childhood vaccine acceptance and refusal among Warao Amerindian caregivers in Venezuela: a qualitative approach. PLoS One 2017; 12:e0170227.^,4444. Simas C, Paterson P, Lees S, Larson HJ. "From my phone, I could rule the world": critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil. Vaccine 2021; 39:4700-4.^,5454. Carcelen AC, Vilajeliu A, Malik F, Gilman RH, Omer S. Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru. Vaccine 2021; 39 Suppl 2:B27-33.^,5757. Fleming JA, Baltrons R, Rowley E, Quintanilla I, Crespin E, Ropero A-M, et al. Implementation of maternal influenza immunization in El Salvador: experiences and lessons learned from a mixed-methods study. Vaccine 2018; 36:4054-61.. For the HPV vaccine, both parents were often involved in the decision to vaccinate ²⁷27. Wong MCS, Wong ELY, Huang J, Cheung AWL, Law K, Chong MKC, et al. Acceptance of the COVID-19 vaccine based on the health belief model: a population-based survey in Hong Kong. Vaccine 2021; 39:1148-56.^,3737. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,3838. Bingham A, Drake JK, LaMontagne DS. Sociocultural issues in the introduction of human papillomavirus vaccine in low-resource settings. Arch Pediatr Adolesc Med 2009; 163:455-61., based on trust in the health system and discussion of sexual practices ³⁹39. Arams R, Weinstock RE, Muresianu ES, O'Callaghan S, Tubridy E, Maita YT, et al. In the name of prevention: maternal perspectives on school-based HPV vaccination in rural southern Chile. Adolesc Health Med Ther 2021; 12:27-36..

Barriers

Lack of information

Participants highlighted aspects related to the lack of guidance on vaccination and post-vaccination, revealing situations in which professionals’ knowledge was below the desired level to provide guidance ²⁸28. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,3434. Melo MCP, Santos MM, Mendes RNC, Sales JRP, Silva RM. Perception of adolescents on immunization in a public school in Petrolina - PE. REME Rev Min Enferm 2013; 17:374-80.^,3737. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,4747. Duarte DC, Viegas S, Lanza FM, Oliveira VC. Vaccination as a scheduled demand: a day in the life of users. Rev Bras Enferm 2020; 73:e20180451.^,5050. Handy LK, Maroudi S, Powell M, Nfila B, Moser C, Japa I, et al. The impact of access to immunization information on vaccine acceptance in three countries. PLoS One 2017; 12:e0180759.^,5151. Ve´liz L, Campos C, Vega P. Conocimiento y actitudes de los padres en relacio´n a la vacunacio´n de sus hijos. Rev Chilena Infectol 2016; 33:30-7.^,5252. Simas C, Larson HJ, Paterson P. "Saint Google, now we have information!": a qualitative study on narratives of trust and attitudes towards maternal vaccination in Mexico City and Toluca. BMC Public Health 2021; 21:1170.^,5656. Duarte DC, Viegas SMF, Augusto TFS, Oliveira VC, Martins JRT, Tholl AD. Organizational aspects and a schedule for access to vaccination from users' perspective. Texto & Contexto Enferm 2021; 30:e20190101.^,5858. Clavé Llavall A, de Wildt G, Meza G, Tattsbridge J, Jones L. Nurses' and teachers' perceived barriers and facilitators to the uptake of the human papilloma virus (HPV) vaccination program in Iquitos, Peru: a qualitative study. PLoS One 2021; 16:e0255218.^,5959. Garcia PJ, George PE, Romero C, Soto G, Carcamo C, Bayer AM. "The flu... is a little more complicated than a cold": knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru. Vaccine 2020; 38:7688-95.^,6060. González-Block MA, Pelcastre-Villafuerte BE, Knauth DR, Fachel-Leal A, Comes Y, Noboa L, et al. Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups. PLoS One 2021; 16:e0256040.^,6161. Islam JY, Hoyt AM, Ramos S, Morgan K, Kim CJ, Sanjose S, et al. Acceptability of two- versus three-dose human papillomavirus vaccination schedule among providers and mothers of adolescent girls: a mixed-methods study in five countries. Cancer Causes Control 2018; 29:1115-30.^,6262. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4.^,6363. Muyulema R, Guerrero Guerrero E, Melendres I. Conocimiento vaccinal en madres con hijos menores de 5 años. Revista Digital de Postgrado 2020; 9:e197.^,6464. Ropero Alvarez AM, Vilajeliu A, Magarinos M, Jauregui B, Guzmán L, Whittenbury A, et al. Enablers and barriers of maternal and neonatal immunization programs in Latin America. Vaccine 2021; 39 Suppl 2:B34-43., in which vaccines were administered without discussion between health professionals and individuals ⁴⁰40. Burghouts J, Del Nogal B, Uriepero A, Hermans PWM, de Waard JH, Verhagen LM. Childhood vaccine acceptance and refusal among Warao Amerindian caregivers in Venezuela: a qualitative approach. PLoS One 2017; 12:e0170227., and in which misinformation was widely disseminated ³⁵35. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6.^,3737. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,5252. Simas C, Larson HJ, Paterson P. "Saint Google, now we have information!": a qualitative study on narratives of trust and attitudes towards maternal vaccination in Mexico City and Toluca. BMC Public Health 2021; 21:1170.^,5454. Carcelen AC, Vilajeliu A, Malik F, Gilman RH, Omer S. Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru. Vaccine 2021; 39 Suppl 2:B27-33.^,6565. Pan American Health Organization. Health in the Americas+, 2017 edition. Summary: regional outlook and country profiles. Washington DC: Pan American Health Organization; 2017.. In particular, participants often underestimated the prevalence of the target disease ²⁸28. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,6666. Oliveira VC, Tavares LOM, Maforte NTP, Silva LNLR, Rennó HMS, Amaral GG, et al. A percepção da equipe de enfermagem sobre a segurança do paciente em sala de vacinação. Rev Cuid (Bucaramanga) 2018; 10:e590. and lacked knowledge about HPV and the vaccine ³⁷37. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,5858. Clavé Llavall A, de Wildt G, Meza G, Tattsbridge J, Jones L. Nurses' and teachers' perceived barriers and facilitators to the uptake of the human papilloma virus (HPV) vaccination program in Iquitos, Peru: a qualitative study. PLoS One 2021; 16:e0255218.^,6767. Fernández ME, Le Y-CL, Fernández-Espada N, Calo WA, Savas LS, Vélez C, et al. Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: a qualitative study. Prev Chronic Dis 2014; 11:E212.^,6868. Silva PMC, Silva IMB, Interaminense INCS, Linhares FMP, Serrano SQ, Pontes CM. Knowledge and attitudes about human papillomavirus and vaccination. Escola Anna Nery Rev Enferm 2018; 22:e20170390.^,6969. Wiesner C, Pin~eros M, Trujillo LM, Cortés C, Ardila J. Aceptabilidad de la vacuna contra el virus papiloma humano en padres de adolescentes, en Colombia. Rev Salud Pública 2010; 12:961-73.. Most mothers were unaware of the difference between special vaccines and those available to the general population, also revealing limited knowledge of basic pediatric vaccination ²⁸28. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53..

“Usually we arrive and are already vaccinated, but nothing is said about the vaccine or about the benefits and pros of the vaccine. Usually, we’ll be vaccinated more by the sense of obligation, sometimes we’re not really aware of the benefits, are we? [...] Look, it was not a service with clarification. The person only takes you to the room where the vaccination will be done and ready, without any kind of guidance” (Brazilian user) ⁴⁷47. Duarte DC, Viegas S, Lanza FM, Oliveira VC. Vaccination as a scheduled demand: a day in the life of users. Rev Bras Enferm 2020; 73:e20180451. (p. 4).

Safety concerns

Safety concerns were very common among pregnant women in relation to their pregnancy and the health of their babies, as participants feared that they could cause deformities and disabilities ⁵²52. Simas C, Larson HJ, Paterson P. "Saint Google, now we have information!": a qualitative study on narratives of trust and attitudes towards maternal vaccination in Mexico City and Toluca. BMC Public Health 2021; 21:1170.^,5454. Carcelen AC, Vilajeliu A, Malik F, Gilman RH, Omer S. Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru. Vaccine 2021; 39 Suppl 2:B27-33.^,5555. Barbieri CL, Couto MT. Decision-making on childhood vaccination by highly educated parents. Rev Saúde Pública 2015; 49:18.^,5959. Garcia PJ, George PE, Romero C, Soto G, Carcamo C, Bayer AM. "The flu... is a little more complicated than a cold": knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru. Vaccine 2020; 38:7688-95.^,7070. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123. and perceived potential side effects, mostly related to fever, local pain ³⁷37. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,5555. Barbieri CL, Couto MT. Decision-making on childhood vaccination by highly educated parents. Rev Saúde Pública 2015; 49:18.^,5959. Garcia PJ, George PE, Romero C, Soto G, Carcamo C, Bayer AM. "The flu... is a little more complicated than a cold": knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru. Vaccine 2020; 38:7688-95.^,7171. Castillo-Neyra R, Buttenheim AM, Brown J, Ferrara JF, Arevalo-Nieto C, Borrini-Mayorí K, et al. Behavioral and structural barriers to accessing human post-exposure prophylaxis and other preventive practices in Arequipa, Peru, during a canine rabies epidemic. PLoS Negl Trop Dis 2020; 14:e0008478., diarrhea, flu, vomiting, delay in the appearance of teeth, headache and abdominal pain ⁴⁰40. Burghouts J, Del Nogal B, Uriepero A, Hermans PWM, de Waard JH, Verhagen LM. Childhood vaccine acceptance and refusal among Warao Amerindian caregivers in Venezuela: a qualitative approach. PLoS One 2017; 12:e0170227.. They believed that the target condition was controlled or not severe enough and that the vaccine was not effective or safe ⁴²42. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14.^,5454. Carcelen AC, Vilajeliu A, Malik F, Gilman RH, Omer S. Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru. Vaccine 2021; 39 Suppl 2:B27-33.^,5757. Fleming JA, Baltrons R, Rowley E, Quintanilla I, Crespin E, Ropero A-M, et al. Implementation of maternal influenza immunization in El Salvador: experiences and lessons learned from a mixed-methods study. Vaccine 2018; 36:4054-61.^,5959. Garcia PJ, George PE, Romero C, Soto G, Carcamo C, Bayer AM. "The flu... is a little more complicated than a cold": knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru. Vaccine 2020; 38:7688-95.^,6060. González-Block MA, Pelcastre-Villafuerte BE, Knauth DR, Fachel-Leal A, Comes Y, Noboa L, et al. Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups. PLoS One 2021; 16:e0256040.. Participants were concerned about potentially harmful components such as mercury ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,5151. Ve´liz L, Campos C, Vega P. Conocimiento y actitudes de los padres en relacio´n a la vacunacio´n de sus hijos. Rev Chilena Infectol 2016; 33:30-7.. Side effects were perceived as a result of the booster doses of some vaccines ⁶³63. Muyulema R, Guerrero Guerrero E, Melendres I. Conocimiento vaccinal en madres con hijos menores de 5 años. Revista Digital de Postgrado 2020; 9:e197.. Safety concerns about the influenza vaccine, even over minor events, were common, especially among pregnant women ⁷7. Gonzalez-Block MA, Arroyo-Laguna J, Rodríguez-Zea B, Pelcastre-Villafuerte BE, Gutiérrez-Calderón E, Díaz-Portillo SP, et al. The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru. Hum Vaccin Immunother 2021; 17:465-74.^,3131. Pereira BFB, Martins MAS, Barbosa TLA, Silva CSO, Gomes LMX. Reasons why pregnant women did not vaccinate against influenza A H1N1. Ciênc Saúde Colet 2013; 18:1745-52.^,5757. Fleming JA, Baltrons R, Rowley E, Quintanilla I, Crespin E, Ropero A-M, et al. Implementation of maternal influenza immunization in El Salvador: experiences and lessons learned from a mixed-methods study. Vaccine 2018; 36:4054-61.^,5959. Garcia PJ, George PE, Romero C, Soto G, Carcamo C, Bayer AM. "The flu... is a little more complicated than a cold": knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru. Vaccine 2020; 38:7688-95.^,7272. Malik AF, Belizan M, Gutierrez M, Vilajeliu A, Sanclemente LN, Gonzalez Casanova I, et al. Pregnant women's perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B44-9.^,7373. Costa e Silva SP, Menandro MC. Representations of the elderly on the influenza vaccine. Ciênc Saúde Colet 2013; 18:2179-88.. Another concern that acted as a barrier to vaccination was the fear of needles ⁷⁴74. Silva PLN, Martins FGS, Galvão APFC, Souto SGT, Oliveira RS, Martins IML. Feelings of pre-adolescents and adolescents vaccination against human papillomavirus. Nursing 2021; 24:5305-10.^,7575. Duarte DC, Oliveira VC, Guimarães EAA, Viegas SMF. Vaccination access in primary care from the user's perspective: senses and feelings about healthcare services. Escola Anna Nery Rev Enferm 2019; 23:e20180250.. For the HPV vaccine, concerns included the lack of long-term studies and side effects such as those observed in Carmen de Bolivar, Colombia (in 2014, hundreds of girls in the town reported various mysterious symptoms after receiving the HPV vaccine ⁷⁶76. Mezza M, Blume S. Turning suffering into side effects: responses to HPV vaccination in Colombia. Soc Sci Med 2021; 282:114135.) ³⁵35. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6.^,3737. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,6767. Fernández ME, Le Y-CL, Fernández-Espada N, Calo WA, Savas LS, Vélez C, et al. Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: a qualitative study. Prev Chronic Dis 2014; 11:E212.^,6969. Wiesner C, Pin~eros M, Trujillo LM, Cortés C, Ardila J. Aceptabilidad de la vacuna contra el virus papiloma humano en padres de adolescentes, en Colombia. Rev Salud Pública 2010; 12:961-73.. Participants were also concerned about the safety and effectiveness of new or experimental vaccines, such as the HIV vaccine ⁷⁷77. Calo WA, Fernandez ME, Fernandez-Espada N, Colon-Lopez V. Exploring the role of ethnic identity on the attitudes towards HPV vaccine advertising among Puerto Ricans: a qualitative analysis. J Immigr Minor Health 2015; 17:314-7.^,7878. Barrington C, Moreno L, Kerrigan D. Perceived influence of an HIV vaccine on sexual-risk behaviour in the Dominican Republic. Cult Health Sex 2008; 10:391-401. and the dengue and Zika vaccines ⁴⁵45. Pérez-Guerra CL, Rodríguez-Acosta RL, Soto-Gómez E, Zielinski-Gutierrez E, Peña-Orellana M, Santiago LM, et al. Assessing the interest to participate in a dengue vaccine efficacy trial among residents of Puerto Rico. Hum Vaccin Immunother 2012; 8:905-15.^,4949. Marbán-Castro E, Villén-Gonzalvo A, Enguita-Fernández C, Romero-Acosta KC, Marín-Cos A, Arrieta GJ, et al. Acceptability of a hypothetical Zika vaccine among women from Colombia and Spain exposed to ZIKV: a qualitative study. Vaccines (Basel) 2020; 8:580.. They also complained about the economic interests of pharmaceutical companies that could drive vaccination programs ³⁰30. Piñeros M, Wiesner C, Cortés C, Trujillo LM. HPV vaccine introduction at the local level in a developing country: attitudes and criteria among key actors. Cad Saúde Pública 2010; 26:900-8.^,4242. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14.^,6060. González-Block MA, Pelcastre-Villafuerte BE, Knauth DR, Fachel-Leal A, Comes Y, Noboa L, et al. Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups. PLoS One 2021; 16:e0256040..

“If children are vaccinated, they immediately get a fever, so they have to give us medication for these diseases. Because of the fever, the child gets hot from the inside, in its belly, and therefore they also vomit and get diarrhoea. Health professionals who vaccinate children do not give us medicine for the diseases caused by these vaccines, and if I go to a medical centre, they can’t help me either. That’s when I get mad” (Venezuelan mother, Warao Amerindian community) ⁴⁰ (p. 8).

Religious and cultural beliefs

Religion can also act as a barrier to some vaccines, particularly in rural areas or among indigenous populations, because of beliefs that health is related to God’s will, that the target disease is caused by supernatural forces that cannot be affected by a vaccine, or that if one’s ancestors survived without a vaccine, it is unnecessary now ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,2828. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,3535. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6.^,3838. Bingham A, Drake JK, LaMontagne DS. Sociocultural issues in the introduction of human papillomavirus vaccine in low-resource settings. Arch Pediatr Adolesc Med 2009; 163:455-61.^,6969. Wiesner C, Pin~eros M, Trujillo LM, Cortés C, Ardila J. Aceptabilidad de la vacuna contra el virus papiloma humano en padres de adolescentes, en Colombia. Rev Salud Pública 2010; 12:961-73.^,7373. Costa e Silva SP, Menandro MC. Representations of the elderly on the influenza vaccine. Ciênc Saúde Colet 2013; 18:2179-88.^,7979. Clavijo GC, Arevalo JD, Pretel VLO, Gutiérrez JP. Percepciones sobre la vacunación de la rabia silvestre en población Awajún de la provincia de Condorcanqui, Amazonas, Perú, 2013. Physis (Rio J.) 2016; 26:201-24.^,8080. Sealy DA, Modeste N, Dyett P. Barriers and facilitators to the HPV vaccine among mothers of adolescent girls: a qualitative study conducted in Trinidad and Tobago. Women Health 2021; 61:235-43.. Indigenous groups perceived that vaccination had a hidden objective of harming them by causing disease and/or sterilizing them, benefiting extractive industries in retaliation for protests ⁴⁰40. Burghouts J, Del Nogal B, Uriepero A, Hermans PWM, de Waard JH, Verhagen LM. Childhood vaccine acceptance and refusal among Warao Amerindian caregivers in Venezuela: a qualitative approach. PLoS One 2017; 12:e0170227.^,7979. Clavijo GC, Arevalo JD, Pretel VLO, Gutiérrez JP. Percepciones sobre la vacunación de la rabia silvestre en población Awajún de la provincia de Condorcanqui, Amazonas, Perú, 2013. Physis (Rio J.) 2016; 26:201-24., or that the vaccine was the mark of the devil ⁷⁹79. Clavijo GC, Arevalo JD, Pretel VLO, Gutiérrez JP. Percepciones sobre la vacunación de la rabia silvestre en población Awajún de la provincia de Condorcanqui, Amazonas, Perú, 2013. Physis (Rio J.) 2016; 26:201-24.. Some participants chose not to get vaccinated because they supported values related to a more natural lifestyle, such as less medical intervention ⁴³43. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por casais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.^,5555. Barbieri CL, Couto MT. Decision-making on childhood vaccination by highly educated parents. Rev Saúde Pública 2015; 49:18.. In Paraguay, the idea that the vaccine could cause the disease was widespread ³²32. Oliveira ACS, Silva GF, Souza JLAC, Maia SMA. Imunização contra influenza em colaboradores de um centro universitário. Enfermagem Brasil 2019; 18:721-6.^,6262. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4..

“Now there are rumours that vaccines are bad, that they bring diseases and that they contain a poison that with time will kill you so that the indigenous people will be exterminated, also because of the number 666, that is why now I am afraid of vaccines. I used to believe that it was effective but with these comments I no longer have confidence” (Peruvian user, Awajú community) ⁷⁹79. Clavijo GC, Arevalo JD, Pretel VLO, Gutiérrez JP. Percepciones sobre la vacunación de la rabia silvestre en población Awajún de la provincia de Condorcanqui, Amazonas, Perú, 2013. Physis (Rio J.) 2016; 26:201-24. (p. 214).

Concerns about vaccination schedules

In relation to the influenza vaccine, although older adults and parents of children showed a clear preference for vaccination, some participants questioned the need for annual vaccination and its effectiveness in some at-risk groups ⁷7. Gonzalez-Block MA, Arroyo-Laguna J, Rodríguez-Zea B, Pelcastre-Villafuerte BE, Gutiérrez-Calderón E, Díaz-Portillo SP, et al. The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru. Hum Vaccin Immunother 2021; 17:465-74.^,5959. Garcia PJ, George PE, Romero C, Soto G, Carcamo C, Bayer AM. "The flu... is a little more complicated than a cold": knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru. Vaccine 2020; 38:7688-95.. In fact, the influenza vaccine was sometimes perceived as having a calendar similar to other vaccines that are administered once or a few times in a person’s lifetime ⁵⁹59. Garcia PJ, George PE, Romero C, Soto G, Carcamo C, Bayer AM. "The flu... is a little more complicated than a cold": knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru. Vaccine 2020; 38:7688-95.. Brazilian participants criticized the schedule and the inefficient use of the vaccination card ⁴²42. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14.^,4747. Duarte DC, Viegas S, Lanza FM, Oliveira VC. Vaccination as a scheduled demand: a day in the life of users. Rev Bras Enferm 2020; 73:e20180451.. The schedule was also criticized in relation to the early age at which infants receive vaccines and the high number of vaccines included ⁴²42. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14.. The individualization of the child’s vaccination in relation to the vaccination calendar was a variation of behavior within the cultural norm of vaccination ⁴³43. Barbieri CLA, Couto MT, Aith FMA. A (não) vacinação infantil entre a cultura e a lei: os significados atribuídos por casais de camadas médias de São Paulo, Brasil. Cad Saúde Pública 2017; 33:e00173315.^,5555. Barbieri CL, Couto MT. Decision-making on childhood vaccination by highly educated parents. Rev Saúde Pública 2015; 49:18..

“I think the vaccine schedule in Brazil is an exaggeration. And in these first years of a child’s life, when the body is so small, I don’t know... It’s a lot of poison for such a little body, in such a short time, so concentrated. So, the idea was never to give the complete schedule” (Brazilian mother) ⁴²42. Couto MT, Barbieri CL. Care and (non)-vaccination in the context of high-income and well-schooled families in Sao Paulo in the state of Sao Paulo, Brazil. Ciênc Saúde Colet 2015; 20:105-14. (p. 112).

Misconceptions and stigma

A common barrier to vaccination against sexually transmitted diseases or diseases perceived to be associated with sexual behavior is stigma ²⁸28. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,3030. Piñeros M, Wiesner C, Cortés C, Trujillo LM. HPV vaccine introduction at the local level in a developing country: attitudes and criteria among key actors. Cad Saúde Pública 2010; 26:900-8.^,5353. Rees HD, Lombardo AR, Tangoren CG, Meyers SJ, Muppala VR, Niccolai LM. Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in Leon, Nicaragua. PeerJ 2017; 5:e3871.^,7878. Barrington C, Moreno L, Kerrigan D. Perceived influence of an HIV vaccine on sexual-risk behaviour in the Dominican Republic. Cult Health Sex 2008; 10:391-401.^,8181. Barrington C, Moreno L, Kerrigan D. Local understanding of an HIV vaccine and its relationship with HIV-related stigma in the Dominican Republic. AIDS Care 2007; 19:871-7.. Cervical cancer was associated with isolation resulting from beliefs about its association with HPV and about it being a sign of sexual promiscuity ⁵³53. Rees HD, Lombardo AR, Tangoren CG, Meyers SJ, Muppala VR, Niccolai LM. Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in Leon, Nicaragua. PeerJ 2017; 5:e3871.. Therefore, vaccination against HPV was perceived as a sign of promiscuous sexual behavior. Misconceptions about HPV and the vaccine are related to safety and a concern that the vaccine would enable sexual relations ³⁰30. Piñeros M, Wiesner C, Cortés C, Trujillo LM. HPV vaccine introduction at the local level in a developing country: attitudes and criteria among key actors. Cad Saúde Pública 2010; 26:900-8.^,3737. Cordoba-Sanchez V, Tovar-Aguirre OL, Franco S, Arias Ortiz NE, Louie K, Sanchez GI, et al. Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: a qualitative study in school-enrolled girls and their parents. Prev Med Rep 2019; 16 Suppl 1:100977.^,3939. Arams R, Weinstock RE, Muresianu ES, O'Callaghan S, Tubridy E, Maita YT, et al. In the name of prevention: maternal perspectives on school-based HPV vaccination in rural southern Chile. Adolesc Health Med Ther 2021; 12:27-36.^,5353. Rees HD, Lombardo AR, Tangoren CG, Meyers SJ, Muppala VR, Niccolai LM. Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in Leon, Nicaragua. PeerJ 2017; 5:e3871.^,6767. Fernández ME, Le Y-CL, Fernández-Espada N, Calo WA, Savas LS, Vélez C, et al. Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: a qualitative study. Prev Chronic Dis 2014; 11:E212.^,6868. Silva PMC, Silva IMB, Interaminense INCS, Linhares FMP, Serrano SQ, Pontes CM. Knowledge and attitudes about human papillomavirus and vaccination. Escola Anna Nery Rev Enferm 2018; 22:e20170390.^,6969. Wiesner C, Pin~eros M, Trujillo LM, Cortés C, Ardila J. Aceptabilidad de la vacuna contra el virus papiloma humano en padres de adolescentes, en Colombia. Rev Salud Pública 2010; 12:961-73.^,8080. Sealy DA, Modeste N, Dyett P. Barriers and facilitators to the HPV vaccine among mothers of adolescent girls: a qualitative study conducted in Trinidad and Tobago. Women Health 2021; 61:235-43.^,8282. Galea JT, Monsour E, Nureña CR, Blas MM, Brown B. HPV vaccine knowledge and acceptability among Peruvian men who have sex with men and transgender women: a pilot, qualitative study. PLoS One 2017; 12:e0172964.^,8383. Petrocy A, Katz ML. Cervical cancer and HPV: knowledge, attitudes, beliefs, and behaviors among women living in Guatemala. J Health Care Poor Underserved 2014; 25:624-36..

“I wouldn’t give my daughter the [HPV] vaccine because in a way it’s telling her to have sex and do what you want” (Colombian parent) ⁶⁹ (p. 966).

Structural problems in health facilities and the health system

From the perspective of users, the main barriers to vaccination were sporadic vaccine shortages at the health facility level ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,3535. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6.^,5252. Simas C, Larson HJ, Paterson P. "Saint Google, now we have information!": a qualitative study on narratives of trust and attitudes towards maternal vaccination in Mexico City and Toluca. BMC Public Health 2021; 21:1170.^,6262. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4.^,6464. Ropero Alvarez AM, Vilajeliu A, Magarinos M, Jauregui B, Guzmán L, Whittenbury A, et al. Enablers and barriers of maternal and neonatal immunization programs in Latin America. Vaccine 2021; 39 Suppl 2:B34-43.^,7575. Duarte DC, Oliveira VC, Guimarães EAA, Viegas SMF. Vaccination access in primary care from the user's perspective: senses and feelings about healthcare services. Escola Anna Nery Rev Enferm 2019; 23:e20180250., long waiting times ²⁸28. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,6464. Ropero Alvarez AM, Vilajeliu A, Magarinos M, Jauregui B, Guzmán L, Whittenbury A, et al. Enablers and barriers of maternal and neonatal immunization programs in Latin America. Vaccine 2021; 39 Suppl 2:B34-43.^,6666. Oliveira VC, Tavares LOM, Maforte NTP, Silva LNLR, Rennó HMS, Amaral GG, et al. A percepção da equipe de enfermagem sobre a segurança do paciente em sala de vacinação. Rev Cuid (Bucaramanga) 2018; 10:e590.^,6767. Fernández ME, Le Y-CL, Fernández-Espada N, Calo WA, Savas LS, Vélez C, et al. Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: a qualitative study. Prev Chronic Dis 2014; 11:E212.^,7272. Malik AF, Belizan M, Gutierrez M, Vilajeliu A, Sanclemente LN, Gonzalez Casanova I, et al. Pregnant women's perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B44-9. and limited working hours, especially for those who could not or did not want to take time off work to get vaccinated ⁷7. Gonzalez-Block MA, Arroyo-Laguna J, Rodríguez-Zea B, Pelcastre-Villafuerte BE, Gutiérrez-Calderón E, Díaz-Portillo SP, et al. The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru. Hum Vaccin Immunother 2021; 17:465-74.^,88. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,2828. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,4747. Duarte DC, Viegas S, Lanza FM, Oliveira VC. Vaccination as a scheduled demand: a day in the life of users. Rev Bras Enferm 2020; 73:e20180451.^,5353. Rees HD, Lombardo AR, Tangoren CG, Meyers SJ, Muppala VR, Niccolai LM. Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in Leon, Nicaragua. PeerJ 2017; 5:e3871.^,5656. Duarte DC, Viegas SMF, Augusto TFS, Oliveira VC, Martins JRT, Tholl AD. Organizational aspects and a schedule for access to vaccination from users' perspective. Texto & Contexto Enferm 2021; 30:e20190101.^,6666. Oliveira VC, Tavares LOM, Maforte NTP, Silva LNLR, Rennó HMS, Amaral GG, et al. A percepção da equipe de enfermagem sobre a segurança do paciente em sala de vacinação. Rev Cuid (Bucaramanga) 2018; 10:e590.^,7070. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123.^,7171. Castillo-Neyra R, Buttenheim AM, Brown J, Ferrara JF, Arevalo-Nieto C, Borrini-Mayorí K, et al. Behavioral and structural barriers to accessing human post-exposure prophylaxis and other preventive practices in Arequipa, Peru, during a canine rabies epidemic. PLoS Negl Trop Dis 2020; 14:e0008478.. Vaccine shortages particularly affected primary care centers and rural and suburban areas. Vaccine supply challenges often resulted from procurement mechanisms, disparities in procurement responsibilities and infrequent delivery schedules. Concerns about the way people were treated by health care providers ⁵²52. Simas C, Larson HJ, Paterson P. "Saint Google, now we have information!": a qualitative study on narratives of trust and attitudes towards maternal vaccination in Mexico City and Toluca. BMC Public Health 2021; 21:1170.^,6363. Muyulema R, Guerrero Guerrero E, Melendres I. Conocimiento vaccinal en madres con hijos menores de 5 años. Revista Digital de Postgrado 2020; 9:e197.^,6464. Ropero Alvarez AM, Vilajeliu A, Magarinos M, Jauregui B, Guzmán L, Whittenbury A, et al. Enablers and barriers of maternal and neonatal immunization programs in Latin America. Vaccine 2021; 39 Suppl 2:B34-43.^,7575. Duarte DC, Oliveira VC, Guimarães EAA, Viegas SMF. Vaccination access in primary care from the user's perspective: senses and feelings about healthcare services. Escola Anna Nery Rev Enferm 2019; 23:e20180250., low quality of care in the public system ⁵²52. Simas C, Larson HJ, Paterson P. "Saint Google, now we have information!": a qualitative study on narratives of trust and attitudes towards maternal vaccination in Mexico City and Toluca. BMC Public Health 2021; 21:1170.^,6464. Ropero Alvarez AM, Vilajeliu A, Magarinos M, Jauregui B, Guzmán L, Whittenbury A, et al. Enablers and barriers of maternal and neonatal immunization programs in Latin America. Vaccine 2021; 39 Suppl 2:B34-43. - in relation to aspects such as the ability of vaccinators to interact effectively with girls in the case of HPV vaccine, for example -, injection safety practices and the quality of services at health facilities ³⁸38. Bingham A, Drake JK, LaMontagne DS. Sociocultural issues in the introduction of human papillomavirus vaccine in low-resource settings. Arch Pediatr Adolesc Med 2009; 163:455-61.^,6666. Oliveira VC, Tavares LOM, Maforte NTP, Silva LNLR, Rennó HMS, Amaral GG, et al. A percepção da equipe de enfermagem sobre a segurança do paciente em sala de vacinação. Rev Cuid (Bucaramanga) 2018; 10:e590.^,7171. Castillo-Neyra R, Buttenheim AM, Brown J, Ferrara JF, Arevalo-Nieto C, Borrini-Mayorí K, et al. Behavioral and structural barriers to accessing human post-exposure prophylaxis and other preventive practices in Arequipa, Peru, during a canine rabies epidemic. PLoS Negl Trop Dis 2020; 14:e0008478.^,7272. Malik AF, Belizan M, Gutierrez M, Vilajeliu A, Sanclemente LN, Gonzalez Casanova I, et al. Pregnant women's perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B44-9. were also reported. Geographical accessibility and adverse climatic conditions that affected travel to health facilities, especially in rural areas, remained a significant barrier ⁷7. Gonzalez-Block MA, Arroyo-Laguna J, Rodríguez-Zea B, Pelcastre-Villafuerte BE, Gutiérrez-Calderón E, Díaz-Portillo SP, et al. The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru. Hum Vaccin Immunother 2021; 17:465-74.^,2828. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,4747. Duarte DC, Viegas S, Lanza FM, Oliveira VC. Vaccination as a scheduled demand: a day in the life of users. Rev Bras Enferm 2020; 73:e20180451.^,5353. Rees HD, Lombardo AR, Tangoren CG, Meyers SJ, Muppala VR, Niccolai LM. Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in Leon, Nicaragua. PeerJ 2017; 5:e3871.^,5656. Duarte DC, Viegas SMF, Augusto TFS, Oliveira VC, Martins JRT, Tholl AD. Organizational aspects and a schedule for access to vaccination from users' perspective. Texto & Contexto Enferm 2021; 30:e20190101.^,6666. Oliveira VC, Tavares LOM, Maforte NTP, Silva LNLR, Rennó HMS, Amaral GG, et al. A percepção da equipe de enfermagem sobre a segurança do paciente em sala de vacinação. Rev Cuid (Bucaramanga) 2018; 10:e590.^,7070. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123.. Health care professionals reported problems reaching certain groups, such as migrants and children who dropped out of school ⁵⁸58. Clavé Llavall A, de Wildt G, Meza G, Tattsbridge J, Jones L. Nurses' and teachers' perceived barriers and facilitators to the uptake of the human papilloma virus (HPV) vaccination program in Iquitos, Peru: a qualitative study. PLoS One 2021; 16:e0255218.^,6262. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4.^,7070. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123..

“It happened to me that there were about two hundred patients in a line in front of me and there was only one-person vaccinating” (Argentine user) ⁷² (p. 4).

In the case of maternal care, some participants switched between the private and public systems; and some physicians in the private sector did not fully follow recommendations for maternal immunization or referred women to the public system to access free vaccination ⁴⁴44. Simas C, Paterson P, Lees S, Larson HJ. "From my phone, I could rule the world": critical engagement with maternal vaccine information, vaccine confidence builders and post-Zika outbreak rumours in Brazil. Vaccine 2021; 39:4700-4.^,6262. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4..

“Many women have their prenatal control at private facilities, and they come late [to the vaccination room], when they already missed the deadline to Tdap, and then sometimes they are not protected against tetanus. They did not get the influenza vaccine. The hepatitis scheme is not appropriate. Every ten pregnant women who are coming to us from the private sector, eight do not have the proper vaccine scheme, because they were not referred here at the right time to get these vaccines in a timely manner” (Brazilian nurse) ⁶²62. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4. (p. 3).

Financial problems

Limited availability of human and material resources, lack of funding for outreach activities, high turnover of health workers and low salaries were barriers mentioned by professionals ⁵⁸58. Clavé Llavall A, de Wildt G, Meza G, Tattsbridge J, Jones L. Nurses' and teachers' perceived barriers and facilitators to the uptake of the human papilloma virus (HPV) vaccination program in Iquitos, Peru: a qualitative study. PLoS One 2021; 16:e0255218.^,6262. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4.^,7070. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123.. Another significant barrier related to the structural barriers described above was the fact that if a vaccine was not available at a public vaccination center, people could not always afford it ⁵⁸58. Clavé Llavall A, de Wildt G, Meza G, Tattsbridge J, Jones L. Nurses' and teachers' perceived barriers and facilitators to the uptake of the human papilloma virus (HPV) vaccination program in Iquitos, Peru: a qualitative study. PLoS One 2021; 16:e0255218.^,6060. González-Block MA, Pelcastre-Villafuerte BE, Knauth DR, Fachel-Leal A, Comes Y, Noboa L, et al. Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups. PLoS One 2021; 16:e0256040.^,6767. Fernández ME, Le Y-CL, Fernández-Espada N, Calo WA, Savas LS, Vélez C, et al. Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: a qualitative study. Prev Chronic Dis 2014; 11:E212.^,7575. Duarte DC, Oliveira VC, Guimarães EAA, Viegas SMF. Vaccination access in primary care from the user's perspective: senses and feelings about healthcare services. Escola Anna Nery Rev Enferm 2019; 23:e20180250.. To avoid out-of-pocket expenses for vaccines, people were directed to the public system ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,7575. Duarte DC, Oliveira VC, Guimarães EAA, Viegas SMF. Vaccination access in primary care from the user's perspective: senses and feelings about healthcare services. Escola Anna Nery Rev Enferm 2019; 23:e20180250.. In addition, there were times when people could not afford transportation to the health facilities where they were to receive vaccines ⁵⁸58. Clavé Llavall A, de Wildt G, Meza G, Tattsbridge J, Jones L. Nurses' and teachers' perceived barriers and facilitators to the uptake of the human papilloma virus (HPV) vaccination program in Iquitos, Peru: a qualitative study. PLoS One 2021; 16:e0255218.^,6060. González-Block MA, Pelcastre-Villafuerte BE, Knauth DR, Fachel-Leal A, Comes Y, Noboa L, et al. Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups. PLoS One 2021; 16:e0256040.^,6767. Fernández ME, Le Y-CL, Fernández-Espada N, Calo WA, Savas LS, Vélez C, et al. Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: a qualitative study. Prev Chronic Dis 2014; 11:E212.^,7575. Duarte DC, Oliveira VC, Guimarães EAA, Viegas SMF. Vaccination access in primary care from the user's perspective: senses and feelings about healthcare services. Escola Anna Nery Rev Enferm 2019; 23:e20180250..

“...the vaccines that are paid, these my boys did not take no, because I cannot afford to pay. As for the meningitis vaccine, I, for example, did not vaccinate them, because it was expensive for me to pay. These payments I wanted to vaccinate my children, but I could not” (Colombian parent) ⁷⁵75. Duarte DC, Oliveira VC, Guimarães EAA, Viegas SMF. Vaccination access in primary care from the user's perspective: senses and feelings about healthcare services. Escola Anna Nery Rev Enferm 2019; 23:e20180250. (p. 4).

Insufficient training of health professionals

Health professionals were vaccinated for their own protection and that of their families and patients ⁸⁴84. Bazán M, Villacorta E, Barbagelatta G, Jimenez MM, Goya C, Bartolini RM, et al. Health workers' attitudes, perceptions and knowledge of influenza immunization in Lima, Peru: a mixed methods study. Vaccine 2017; 35:2930-6.. Health care providers reported inadequate training in immunization, including for childhood vaccines. Vaccination service professionals were unaware of vaccination coverage and drop-out rates in the territory ⁶²62. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4.^,8585. Aragão RF, Albuquerque IMN, Ribeiro MA, Barreto RM, Sousa JA. Percepções e conhecimentos da equipe de enfermagem sobre o processo de imunização. Rev Bras Promoç Saúde 2019; 32:1-8.. Health authorities praised the scientific events sponsored by the vaccine industry and found the information provided by manufacturers very useful ³⁰30. Piñeros M, Wiesner C, Cortés C, Trujillo LM. HPV vaccine introduction at the local level in a developing country: attitudes and criteria among key actors. Cad Saúde Pública 2010; 26:900-8..

“I would have liked more, in fact today we were talking with my colleagues about the issue of saying for example where we could do a course, a course, in which they give us a certificate that we did the course about vaccines” (Argentine nurse) ⁶²62. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4. (p. 3).

Social violence

In El Salvador, Honduras, Ecuador and Colombia, fear of crime and social violence by gang members was cited as a barrier to vaccination, as limited access to health facilities undermined outreach efforts ⁵⁷57. Fleming JA, Baltrons R, Rowley E, Quintanilla I, Crespin E, Ropero A-M, et al. Implementation of maternal influenza immunization in El Salvador: experiences and lessons learned from a mixed-methods study. Vaccine 2018; 36:4054-61.^,6464. Ropero Alvarez AM, Vilajeliu A, Magarinos M, Jauregui B, Guzmán L, Whittenbury A, et al. Enablers and barriers of maternal and neonatal immunization programs in Latin America. Vaccine 2021; 39 Suppl 2:B34-43.^,7070. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123..

“In this area, there are already hot zones, such as the northern zone, where there is a displaced population and conflicts have arisen. During the last vaccination campaign, we were unable to proceed due to an armed strike. It is challenging to send a team as they are at risk of being robbed” (Colombian professional) ⁷⁰70. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123. (p. 3).

Discussion

Among the facilitators, vaccination was recognized as an effective strategy to prevent infectious diseases, but also as a prerequisite for access to important benefits such as social assistance, schooling or a job. Recommendations from health professionals and positive experiences with health services were also identified as facilitators. The main barriers to vaccination were lack of information or advice, structural problems such as shortages of vaccines and limited opening hours of health facilities, inability to afford over-the-counter vaccines or transportation to health facilities, certain religious beliefs, misconceptions and safety concerns. Our findings highlight the multifaceted nature of vaccine acceptance and hesitancy, shedding light on factors at different levels. The identification of facilitators underscores the role of informed decision-making and trusted sources of information, while the barriers emphasize the challenges that need to be addressed to ensure equitable vaccine access and uptake.

Following the initial search for this review, additional studies on the COVID-19 vaccine were identified, enriching our findings. In Grenada, trust in medical advice, vaccine efficacy and travel and social activity mandates facilitated vaccination, while barriers included the perceived low threat of COVID-19, preference for natural remedies and concerns about accessibility and misinformation ⁸⁶86. Herry AM, Greaves D, Smith P, Toledo NA, Wildman A, Wildman T, et al. Facilitators of and barriers to COVID-19 vaccination in Grenada: a qualitative study. Rev Panam Salud Pública 2023; 47:e44.. In Argentina, vaccine acceptance was high, driven by social responsibility arguments, but doubts about safety and adverse effects persisted, particularly among educated mothers ⁸⁷87. Bruno D, Pereira A, Mena MF, Demonte F. Tensiones entre la aceptación social y la reticencia individual a la vacunación: la perspectiva de padres y madres que residen en la Ciudad Autónoma de Buenos Aires en contexto de pandemia por COVID-19. Salud Colect 2022; 18:e4258.. In Peru, vaccine efficacy, long-term health effects and government information influenced vaccination decisions, with some people perceiving promotional strategies as a violation of human rights ⁸⁸88. Tenorio-Mucha J, Portocarrero J, Busta-Flores P, Pesantes MA, Lazo-Porras M. Perceptions of acceptance and reluctance to COVID-19 vaccination in Peru. Rev Peru Med Exp Salud Pública 2022; 39:274-80.. Brazilian nurses identified both strengths, such as teamwork and innovative interventions, and weaknesses, such as lack of training and communication, in the immunization campaign. In addition, reports of childhood vaccine hesitancy revealed fears about the experimental status of vaccines, misinformation and the key role of health professionals in rebuilding trust ⁸⁹89. Souto EP, Fernandez MV, Rosario CA, Petra PC, Matta GC. Hesitação vacinal infantil e COVID-19: uma análise a partir da percepção dos profissionais de saúde. Cad Saúde Pública 2024; 40:e00061523.. For the first time, public media disseminated misinformation and discouraged vaccination, which was linked to the lack of government coordination in vaccination efforts, a significant contributor to vaccine hesitancy ⁸⁹89. Souto EP, Fernandez MV, Rosario CA, Petra PC, Matta GC. Hesitação vacinal infantil e COVID-19: uma análise a partir da percepção dos profissionais de saúde. Cad Saúde Pública 2024; 40:e00061523.. Discursive conflicts surrounding COVID-19, including some that minimized the severity of the disease, led to an underestimation of the importance of achieving collective immunity via vaccination ⁸⁹89. Souto EP, Fernandez MV, Rosario CA, Petra PC, Matta GC. Hesitação vacinal infantil e COVID-19: uma análise a partir da percepção dos profissionais de saúde. Cad Saúde Pública 2024; 40:e00061523.. Among indigenous populations in Guatemala, barriers to vaccination included a lack of culturally sensitive information, misinformation due to mistrust of the government and access issues ⁹⁰90. Skinner NA, Sanders K, Lopez E, Mux MSS, Miguel LA, Vosburg KB, et al. Barriers to COVID-19 vaccine acceptance to improve messages for vaccine uptake in indigenous populations in the central highlands of Guatemala: a participatory qualitative study. BMJ Open 2023; 13:e067210.. Religion also played a complex role, potentially facilitating or hindering vaccination efforts ⁹⁰90. Skinner NA, Sanders K, Lopez E, Mux MSS, Miguel LA, Vosburg KB, et al. Barriers to COVID-19 vaccine acceptance to improve messages for vaccine uptake in indigenous populations in the central highlands of Guatemala: a participatory qualitative study. BMJ Open 2023; 13:e067210.. Based on these findings, it is appropriate to examine the politicization of the vaccine and the impact of this particular vaccine on people’s confidence in other vaccines.

Our findings are consistent with those described in a recent review of barriers in the Latin American region, which also cited issues such as inadequate information from health authorities and lack of awareness of the availability, effectiveness and safety of certain vaccines ¹⁷17. Guzman-Holst A, DeAntonio R, Prado-Cohrs D, Juliao P. Barriers to vaccination in Latin America: a systematic literature review. Vaccine 2020; 38:470-81.. In other low- and middle-income countries, concerns about adverse effects of immunization and mistrust of immunization programs were the most common barriers ²⁴24. Cobos Munoz D, Monzon Llamas L, Bosch-Capblanch X. Exposing concerns about vaccination in low- and middle-income countries: a systematic review. Int J Public Health 2015; 60:767-80.. In high-income settings, barriers included misleading knowledge, beliefs and perceptions about vaccines and general negative attitudes towards vaccination ⁹¹91. Tabacchi G, Costantino C, Napoli G, Marchese V, Cracchiolo M, Casuccio A, et al. Determinants of European parents' decision on the vaccination of their children against measles, mumps and rubella: a systematic review and meta-analysis. Hum Vaccin Immunother 2016; 12:1909-23.. Several socioeconomic factors affected vaccine uptake in all settings, such as ethnicity and low socioeconomic status ⁹¹91. Tabacchi G, Costantino C, Napoli G, Marchese V, Cracchiolo M, Casuccio A, et al. Determinants of European parents' decision on the vaccination of their children against measles, mumps and rubella: a systematic review and meta-analysis. Hum Vaccin Immunother 2016; 12:1909-23..

Some barriers to vaccination are related to the health system and service delivery. Inability to obtain vaccines at health facilities due to vaccine shortages ⁹9. Brown AL, Sperandio M, Turssi CP, Leite RMA, Berton VF, Succi RM, et al. Vaccine confidence and hesitancy in Brazil. Cad Saúde Pública 2018; 34:e00011618.^,3535. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6., long waiting times and limited vaccination schedules ⁸8. Simas C, Larson HJ, Paterson P. "Those who do not vaccinate don't love themselves, or anyone else": a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama. BMJ Open 2021; 11:e044903.^,2828. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53. were barriers identified in this review. This wide range of problems exacerbates existing programmatic and health system challenges to childhood immunization services ²⁴24. Cobos Munoz D, Monzon Llamas L, Bosch-Capblanch X. Exposing concerns about vaccination in low- and middle-income countries: a systematic review. Int J Public Health 2015; 60:767-80., such as lack of resources at health facilities (e.g., lack of human and financial resources for outreach activities). At the policy level, several studies have identified compulsory vaccination as a facilitator of school enrolment and access to key social benefits ³⁵35. Liebermann E, Van Devanter N, Frias Gúzman N, Ompad D, Shirazian T, Healton C. Parent-level barriers and facilitators to HPV vaccine implementation in Santo Domingo, Dominican Republic. J Community Health 2020; 45:1061-6.^,4848. Santos L, Barreto C, Silva F, Silva K. Percepção das mães quanto à importância da imunização infantil. Rev Rene 2011; 12:621-6..

Barriers to access to health services that limit the demand for vaccines were also identified, such as geographical barriers and lack of resources to travel to health centers. In some Central American countries, social violence was also mentioned as a problem for access to health facilities ⁵⁷57. Fleming JA, Baltrons R, Rowley E, Quintanilla I, Crespin E, Ropero A-M, et al. Implementation of maternal influenza immunization in El Salvador: experiences and lessons learned from a mixed-methods study. Vaccine 2018; 36:4054-61.. There are also barriers and facilitators at the social and interpersonal levels. As noted in another review, trust in the recommendations of health care providers is one of the main reasons why vaccine-hesitant parents change their minds, and parents who receive information from physicians are less vaccine-hesitant than those who receive information from other sources ⁹²92. Dube E, Gagnon D, MacDonald N, Bocquier A, Peretti-Watel P, Verger P. Underlying factors impacting vaccine hesitancy in high income countries: a review of qualitative studies. Expert Rev Vaccines 2018; 17:989-1004.. In fact, decisions are strongly influenced by trust in vaccine information, both in terms of content and source ⁹²92. Dube E, Gagnon D, MacDonald N, Bocquier A, Peretti-Watel P, Verger P. Underlying factors impacting vaccine hesitancy in high income countries: a review of qualitative studies. Expert Rev Vaccines 2018; 17:989-1004.. Fear of vaccine side effects and distrust of the pharmaceutical industry are also common barriers. Our findings show a lack of information from the community and a need for reliable information ²⁸28. Sherlock MSM, Cardoso MVLML, Le´lis ALPA, Lopes MMCO, Pereira MLD. Reasons for non-compliance of mothers to immunization schedule of children exposed to HIV. Rev Rene 2013; 14:341-53.^,3434. Melo MCP, Santos MM, Mendes RNC, Sales JRP, Silva RM. Perception of adolescents on immunization in a public school in Petrolina - PE. REME Rev Min Enferm 2013; 17:374-80., which contrasts with the lack of time and training in communication skills on the part of some health professionals ⁷⁰70. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123..

At the societal level, stigma was identified as a barrier to HPV vaccination because of the community’s association of HPV vaccine demand with sexual promiscuity or early sexual initiation ⁵³53. Rees HD, Lombardo AR, Tangoren CG, Meyers SJ, Muppala VR, Niccolai LM. Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in Leon, Nicaragua. PeerJ 2017; 5:e3871.. Low risk perception among younger children and parents was a barrier to HPV vaccination. This was particularly evident in populations in which religious beliefs discourage premarital sexual activity. Parents were often concerned about the potential encouragement of sexual activity associated with vaccination and the difficult conversations associated with vaccination decisions due to the inherent link to sexuality. Lack of familiarity with the new HPV vaccine leads to concerns about safety and efficacy ⁹³93. Marshall S, Fleming A, Moore AC, Sahm LJ. Views of parents regarding human papillomavirus vaccination: a systematic review and meta-ethnographic synthesis of qualitative literature. Res Social Adm Pharm 2019; 15:331-7.. Strategies to improve vaccination coverage should be sensitive to cultural beliefs, socioeconomic disparities and regional differences. In addition, policy efforts should consider the societal impact of stigma and the potential influence of religious norms on vaccination decisions.

Several studies have identified barriers to migrant vaccination ⁶²62. Malik FA, Alonso JP, Sanclemente LN, Vilajeliu A, Gutierrez M, Gonzalez-Casanova I, et al. Health care providers perspectives about maternal immunization in Latin America. Vaccine 2021; 39 Suppl 2:B50-4.^,7070. Escobar-Díaz F, Osorio-Merchán MB, De la Hoz-Restrepo F. Reasons some children under 5 do not get vaccinated in four Colombian cities. Rev Panam Salud Pública 2017; 41:e123., but no studies have examined this issue in depth. Many barriers to migrant vaccination when arriving in a new country arise from a lack of information about vaccination and concerns about side effects, safety and low efficacy ⁹⁴94. Wilson L, Rubens-Augustson T, Murphy M, Jardine C, Crowcroft N, Hui C, et al. Barriers to immunization among newcomers: a systematic review. Vaccine 2018; 36:1055-62.. Engaging with newcomer communities and leaders to better understand their concerns can be beneficial in addressing these concerns and promoting vaccination in ways that are accessible and acceptable to these citizens ⁹⁴94. Wilson L, Rubens-Augustson T, Murphy M, Jardine C, Crowcroft N, Hui C, et al. Barriers to immunization among newcomers: a systematic review. Vaccine 2018; 36:1055-62..

The review has important limitations. In addition to selection and publication bias, most of the studies identified were concentrated in a few countries, and certain barriers are context-specific. The heterogeneity of methodological designs, quality of reporting, populations and types of vaccines made it difficult to synthesize the findings. In addition, there were very few publications on barriers to vaccination in subpopulations such as adolescents, migrants and indigenous groups. Most studies investigating determinants of HPV vaccination decisions focused on parents of adolescents. Lastly, some studies addressed the experience of vaccination during the COVID-19 pandemic and the implementation of mass vaccination campaigns; however, the impact of these processes on perceptions of vaccination policy in general was not fully known at the time, although the negative impact of the pandemic on attitudes towards vaccination was documented.

To our knowledge, this is the first systematic review of qualitative studies on the determinants of vaccination in Latin America. The main barriers to vaccination were lack of information or advice, shortages of vaccines, limited hours of operation, long distances to health facilities, certain religious beliefs, misconceptions and safety concerns. Factors identified as facilitators included perceptions of vaccine protection, recommendations from health professionals, positive experiences with health services and positive community attitudes towards vaccines. Our findings emphasize the need for tailored communication strategies that provide accurate and accessible information and build trust in immunization programs. Addressing structural issues such as vaccine shortages is also crucial for enhancing vaccine accessibility. By identifying both barriers and facilitators, this study provides a roadmap for designing effective interventions and policies that can increase vaccine acceptance, improve access to vaccination services and ultimately contribute to improved public health outcomes throughout Latin America.

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