Effectiveness of CONFIVAC, an intervention to enhance Paediatric Nurses and Paediatricians skills to promote vaccination: a mixed-methods cluster randomised clinical trial

Effectiveness of CONFIVAC, an intervention to enhance Paediatric Nurses and Paediatricians skills to promote vaccination: a mixed-methods cluster randomised clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of CONFIVAC, an intervention to enhance Paediatric Nurses and Paediatricians skills to promote vaccination: a mixed-methods cluster randomised clinical trial Elena Roel, Elisabet Henderson, Sara Valmayor, Victoria Porthé, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6021302/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Vaccine hesitancy (VH) poses a significant challenge to achieving optimal vaccination coverages worldwide. Paediatric healthcare workers (PHCWs) are fundamental in promoting vaccination but often lack adequate training to address VH. We designed CONFIVAC, an evidence-based training program developed using intervention mapping to enhance PHCWs' knowledge, self-efficacy, and skills in managing VH and fostering a culture of immunization in primary care. This study aimed to evaluate its effectiveness. Methods We conducted a mixed methods study including a cluster-randomized controlled trial with142 PHCWs in Barcelona and Central Catalonia, Spain from October 2023 to February 2024 and a qualitative study using a thematic analysis. Paediatric teams were randomized into intervention (CONFIVAC) and control (standard care) arms. CONFIVAC included 12 hours of online and in-person training on vaccine knowledge, communication strategies, and organizational tools. Outcomes were assessed through self-administered questionnaires at baseline (T0) and four months later (T1). Key outcomes included vaccine-promoting behaviours (presumptive communication, anticipation of upcoming vaccines, and explicit vaccine recommendations) and self-perception of adequate training to handle VH. We performed logistic regression models to estimate odds ratios (OR) with 95% confidence intervals using an intention-to-treat approach. Focus groups provided qualitative insights. Results At T1, PHCWs in the intervention arm were more likely to use presumptive communication (aOR: 4.05 [2.30;7.15]) and anticipate upcoming vaccines (aOR: 2.64 [1.50;4.65]) than controls. Explicitly recommending vaccination when encountering cases of VH did not reach statistical significance (aOR: 1.75 [0.89;3.44]). Self-perception of adequate training was higher in the intervention arm (aOR: 3.85 [2.10;7.03]). Satisfaction with the training was high, and focus group participants reported improved communication strategies, more empathy towards VH families, and increased confidence in managing VH situations. Discussion CONFIVAC enhanced PHCWs' vaccine-promoting behaviours and self-efficacy, demonstrating the value of accessible, evidence-based training programs to support vaccination efforts in routine practice. Trial registration ClinicalTrials NCT06489236 Vaccination hesitancy Vaccination Paediatrics Education Professional Communication Cluster Randomised Clinical Trial Figures Figure 1 Figure 2 Figure 3 Introduction Vaccine hesitancy (VH) is one of the top ten threats to global health [ 1 ]. VH, defined as the delay or refusal to accept vaccines despite their availability, is a complex phenomenon that can manifest in varying degrees of indecision or refusal regarding some or all vaccines [ 2 ]. Although vaccination is one of the most cost-effective measures in public health [ 3 ], misinformation and anti-vaccine discourses are on the rise across social media platforms, a trend further amplified by the COVID-19 pandemic [ 4 – 7 ]. This might have contributed to declining public confidence in vaccines in Europe in recent years [ 8 ]. Most vaccines are administered during childhood following national immunisation schedules [ 9 ]. Primary paediatric healthcare workers (PHCW), including nurses and paediatricians, are primarily responsible for promoting these vaccines and play a critical role in influencing parental decisions [ 6 , 10 – 12 ]. However, the manner in which PHCWs convey vaccination recommendations can significantly affect vaccine acceptance [ 13 , 14 ]. Up-to-date vaccine knowledge, along with strong communication and organisational strategies, are essential for building trust with caregivers and promoting vaccination [ 7 , 15 , 16 ]. Many PHCWs, however, might feel unprepared to effectively handle families’ vaccination doubts [ 6 , 17 , 18 ]. A study conducted in Barcelona, Spain, revealed that 30% of PHCWs felt they lacked adequate information and training to effectively address families' concerns, while over half expressed a desire for more vaccine-related information [ 19 ]. While some interventions have aimed to train PHCWs in addressing VH, most have been limited in scope. Predominantly conducted in the US, these interventions typically focus on theoretical knowledge, communication skills, or a combination of both, target mainly physicians, and are often limited to a single vaccine (e.g., influenza)[ 20 ]. Moreover, they tend to overlook the emotional burden experienced by PHCWs when addressing VH. To address these limitations, we developed CONFIVAC, an intervention based in behavioural theories, models, and frameworks designed to enhance PHCW’s attitudes, skills and behaviours in promoting vaccination [ 21 ]. CONFIVAC comprises ten hours of asynchronous theoretical online training followed by two hours of in-person practical training featuring role-playing exercises. The program is built on three key pillars: 1) reinforcing knowledge about vaccines and countering misinformation; 2) building evidence-based communication skills to promote vaccination and address VH in consultations; and 3) learning and implementing organisational strategies to promote vaccination within paediatric consultations and healthcare teams. A detailed study protocol including a comprehensive description of the program design, content, and evaluation plan, is available elsewhere [ 21 ]. In 2023–2024, we implemented CONFIVAC among PHCWs working in two northeastern regions of Spain, Barcelona city and Central Catalonia. The aim of this study is to evaluate the effectiveness of CONFIVAC in improving knowledge, beliefs, self-efficacy and vaccine-promoting behaviours as well as to assess the implementation process using a mixed methods evaluation design. Methods Study design We conducted a mixed-methods study, including a two-arm parallel cluster randomised controlled trial targeting PHCWs in Barcelona city and Central Catalonia alongside a qualitative study from a phenomenological perspective. Setting This study was conducted between October 2023 and February 2024 in Barcelona and Central Catalonia. Spain has a free, public health system in which systematic childhood vaccines are mostly delivered as part of routine care provided by public primary paediatric healthcare (PPH) teams, who serve the population living within their assigned territorial areas. In 2023, Barcelona had 41 PPH teams, with approximately 340 PHCW serving 194,000 children whereas Central Catalonia had 38 PPH teams, with approximately 110 PHCW serving 76,000 children across both rural and urban areas. Eligibility criteria The inclusion criteria were being a paediatrician or paediatric nurse from a PPH team in Barcelona or Central Catalonia. The exclusion criteria were having previously participated in the design of the intervention or being a resident (either medical or nursing) due to their status as temporary staff in training programs Recruitment We invited all PHCWs from PPH teams in Barcelona and Central Catalonia through email invitations that included a brochure summarising the research project, the contents of the free training program, and the incentives for participation, which included 2.5 educational credits and a certificate of participation in research. Email invitations were distributed hierarchically, starting with the heads of paediatrics in each region, followed by PPH team directors, and then forwarded to PHCWs within each PPH team. We also conducted an online information session. PHCWs interested in joining the study were pre-enrolled by completing a brief online form, accessible through the brochure. The flowchart of the study is shown in Fig. 1 . A total of 174 potential participants were assessed for eligibility. Two were excluded for not meeting inclusion criteria: one was a dentist, and the other was a nurse working exclusively in adult care. Assignment of intervention To minimise contamination, we used cluster randomisation. A total of 29 PPH teams from Barcelona and 26 PPH teams from Central Catalonia (i.e., the teams from PHCW pre-enrolled) were paired according to the total population served, socioeconomic status, vaccination coverage, and region (Barcelona or Central Catalonia). Within each pair, individuals were randomly assigned to one of the two parallel arms: intervention or control arm (standard care). The intervention arm received the intervention from October 2023 to February 2024 (autumn course edition), whereas the control arm was offered the course for ethical reasons after data collection had ended, from February 2024 to June 2024 (spring edition). Prior to enrolment PHCWs were informed that they could neither choose nor know their assigned course edition before baseline data collection. Following randomisation, participants were granted access to the online learning platform (Moodle). Enrolment was completed upon reviewing the participant information sheet and providing signed informed consent on the platform. Out of the 172 individuals who were cluster-randomized, 142 participants signed the informed consent. Of these,77 were assigned to the intervention arm (from 29 PPH teams) and 65 to the control arm (from 25 PPH teams). The imbalance by study arm in participant and team allocation numbers was due to variations in enrolment completion rates and the number of participants per team (median of 2 per team, range from 1 to 10). Data collection Participants filled a questionnaire at baseline (T0) and again four months later (T1). The online training was available from October to December 2023, while group in-person training sessions —conducted in small groups— took place in January 2024. At least one-month elapsed between the last in-person session and T1. The questionnaire was developed ad hoc using items from previously validated questionnaires to assess changes in the identified psychosocial determinants of vaccination and was pre-tested and pilot tested [ 22 – 24 ]. PHCWs’ knowledge and beliefs about the safety and effectiveness of childhood vaccines, self-efficacy in managing vaccine hesitancy, frequency of vaccine promotion behaviours during paediatric visits, and perception of having sufficient training to address VH were measured using five-point Likert questions. The use of organisational tools within paediatric visits and at the PPH team level were as well as sociodemographic information (age, sex, role, years of practice, and parenthood) were also collected. Participants in the intervention arm were also asked to fill a satisfaction survey at the end of the training program. Both questionnaires can be consulted in the study protocol [ 21 ]. Outcomes Key effectiveness outcomes included the frequency of vaccine promoting behaviours (use of presumptive communication, anticipate upcoming vaccines, recommend vaccination explicitly in cases of VH) measured on a scale ranging from “Never” to “Always”, and the perception of having sufficient training to address VH, measured on a scale from “Completely disagree” to “Completely agree”. As a secondary outcome, we assessed self-efficacy in managing vaccine-hesitancy using a 17-item questionnaire with responses recorded on a five-point Likert scale ranging from "Very incapable" (0 points) to "Very capable" (3 points), yielding a total score range from 0 to 68 points. Higher scores indicate greater self-efficacy. We also reported as secondary outcomes the remaining aspects assessed in the questionnaire: vaccine-related knowledges and beliefs, and the use of organizational tools to promote vaccination within primary teams. Main process outcomes included overall satisfaction (rated on a 0–10 scale), likelihood of recommending CONFIVAC to a colleague (yes/no), and perceived applicability of the training (measured on a five-point Likert scale ranging from “A lot” to “Very little”). Secondary outcomes comprised the remaining items included in the satisfaction survey. Statistical analysis We described participant’s baseline demographic characteristics as well as main and secondary effectivity outcomes at baseline (T0) and post-intervention (T1) by allocation arm. We also described the results of the satisfaction survey. Categorical variables were summarised using counts and percentages, while continuous variables were described using means with standard deviations (SD). Differences in self-efficacy scores between the two arms at T0 and T1 were compared using a t-test, with a significance level set at p < 0.05. To assess the intervention's effectiveness, we initially planned to estimate multi-level ordinal logistic regression models. However, due to insufficient observations at certain levels (i.e., several PPH teams had only one participant) and the violation of the proportional odds assumption, we performed single-level logistic regression models. Outcomes were dichotomised as 0/1, where 1 represented the most favourable response category (e.g., Always for behaviour-related outcomes). This decision was based on a preliminary analysis of data at T0, which revealed that participants had already a high baseline level across most outcomes. Odds Ratios were estimated along with 95% confidence intervals. We estimated baseline-adjusted models (adjusting for values at T0) as well as fully adjusted models (adjusting for values at T0, gender, parenthood status, occupation, years of professional practice, and region). Logistic regressions were performed on an intention-to-treat basis, with participants lost to follow-up being assigned their baseline values at T1. All analyses were conducted using R software (version 4.3.0). Qualitative study A qualitative phenomenological study was designed to evaluate both the effectiveness and the process, based on participants' perceptions. The sample was intentionally designed among the intervention arm participants using predefined profiles to ensure diversity in gender, experience, rurality, parenthood, socioeconomic status, exam attempts, and satisfaction. To encourage participation, a small economic incentive was provided in the form of a gift card. Final sample consisted of 26 PHCWs, who participated in 4 focus groups (2 with paediatricians and 2 with nurses). Focus groups were held online via Teams in March 2024, with 6 to 8 participants per group and lasted 1.5 to 2 hours. A topic guide was developed to structure the discussion (Supplementary Material 1). Sessions were recorded with participant consent and transcribed using Turboscribe. The transcriptions were subsequently reviewed by the research team. We conducted a thematic content analysis [ 25 ], with the support of the software ATLAS.ti version 24.1. Themes were coded and classified, identifying common patterns as well as convergences and divergences in the data. Analytical categories were derived from the topic guide and through constant comparison of the data. To ensure the quality of the information, the data were triangulated among the research team. Ethics The study was conducted in accordance with the Declaration of Helsinki and approved by the Drug Research Ethics Committee Parc de Salut MAR (CEIm-PSMAR)( 2021/9729/I) and by IDIAP Jordi Gol Clinical Research Ethics Committee (CEIm)(22/194-P). This study was registered on 5th July 2024 at ClinicalTrials.gov under the ID NCT06489236. Results Baseline characteristics of participants were similar in both study arms (Table 1 ). Most participants were women (93.0%), nurses (66.9%), had children (75.4%), and had encountered VH families in the prior 4 months (90.8%). Participants were evenly distributed by region, with 56.3% being from Barcelona. Seven participants were lost to follow-up, with baseline characteristics similar to those who completed the study (Supplementary Material Table 1). One participant was excluded from the analyses due to responding do not know to all items. A description of the characteristics of PHCWs that participated in the qualitative study can be found in Table 2 . Table 1 Characteristics of study participants. CONFIVAC, 2024. Variable Control Intervention p-value n 65 77 Age, mean (SD) 44.8 (9.4) 45.7 (10.7) 0.617 Gender, n (%) Woman 61 (93.8) 71 (92.2) 0.959 Man 4 (6.2) 6 (7.8) Region, n (%) Barcelona 33 (50.8) 47 (61.0) 0.289 Central Catalonia 32 (49.2) 30 (39.0) Parenthood, n (%) 51 (78.5) 56 (72.7) 0.552 Occupation, n (%) Physician 25 (38.5) 22 (28.6) 0.285 Nurse 40 (61.5) 55 (71.4) Years of work experience, mean (SD) 19.6 (9.5) 20.1 (10.6) 0.793 Encountered a vaccine hesitant family in the prior 4 months at baseline, n (%) 58 (89.2) 71 (92.2) 0.748 Lost to follow-up, n (%) 3 (4.6) 4 (5.2) 1.000 Notes: p-values were calculated using Student's t-tests for continuous variables and chi-square tests for categorical variables. Vaccine hesitant families include those who had doubts about vaccines. Abbreviations: SD: standard deviation. Table 2 Characteristics of participants in focus group discussions. CONFIVAC, 2024 Informant Occupation Gender Years of professional experience Region Overall satisfaction (0–10) N1 Nurse Woman ≥ 30 Barcelona Missing N2 Nurse Woman 10–29 Barcelona 8 N3 Nurse Woman 10–29 Central Catalonia Missing N4 Nurse Woman ≥ 30 Central Catalonia 10 N5 Nurse Woman < 10 Central Catalonia Missing N6 Nurse Woman < 10 Central Catalonia 9 N7 Nurse Woman 10–29 Barcelona 8 N8 Nurse Woman ≥ 30 Central Catalonia 9 N9 Nurse Woman 10–29 Barcelona Missing N10 Nurse Woman 10–29 Central Catalonia 8 N11 Nurse Woman 10–29 Barcelona 10 N12 Nurse Woman < 10 Barcelona 8 N13 Nurse Woman ≥ 30 Central Catalonia Missing N14 Nurse Woman 10–29 Central Catalonia Missing P1 Paediatrician Man < 10 Barcelona 9 P2 Paediatrician Woman 10–29 Barcelona Missing P3 Paediatrician Woman ≥ 30 Barcelona 8 P4 Paediatrician Woman 10–29 Central Catalonia 7 P5 Paediatrician Woman ≥ 30 Central Catalonia 9 P6 Paediatrician Man 10–29 Central Catalonia 10 P7 Paediatrician Woman 10–29 Barcelona Missing P8 Paediatrician Woman 10–29 Central Catalonia 10 P9 Paediatrician Man ≥ 30 Barcelona 8 P10 Paediatrician Woman 10–29 Central Catalonia 10 Paediatrician Woman ≥ 30 Barcelona 8 P12 Paediatrician Woman < 10 Barcelona 8 Effectiveness evaluation Behavioural changes Figure 2 and Table 3 illustrate changes in vaccine promotion behaviours from T0 to T1. The proportion of participants who always initiate vaccination conversations using presumptive communication increased by 28% in the intervention arm (43–71%) compared to a 2% increase in the control arm (37–39%). Similarly, the proportion of participants who always anticipate upcoming vaccines increased by 16% in the intervention arm (57–73%) while it decreased by 5% in the control arm (55–50%). The proportion of participants who always explicitly recommend vaccination in cases of VH increased slightly by 3% in the intervention arm (32–35%) compared to no change in the control arm (26% at both time points). These differences were statistically significant for presumptive communication [aOR: 4.05 (95% CI: 1.64–10.92)] and anticipating upcoming vaccines [aOR: 2.64 (95% CI: 1.15–6.26)] but not for explicitly recommending vaccination [aOR: 2.18 (95% CI: 0.86–5.76)]. Changes in perception of having sufficient training and self-efficacy to handle VH are shown in Fig. 3 and Table 3 . The proportion of participants who completely agreed they had sufficient training to address vaccination concerns increased by 17% in the intervention arm (17–34%) and decreased by 7% in the control arm (23–16%). This difference was statistically significant [aOR: 4.05 (95% CI: 1.64–10.92)]. In terms of self-efficacy, both arms had similar scores at T0, with a mean (SD) score of 52.5 (7.9) for the control arm and 52.9 (8.1) for the intervention arm (p = 0.74). By T1, the score remained stable in the control arm (mean: 51.6 [9.1]) whereas it increased in the intervention arm to 57.1 (8.3). The mean difference between the two arms at T1 was 5.5 points, with a 95% confidence interval of 2.6 to 8.5 (p < 0.001). Responses to the self-efficacy score questionnaire are reported in Supplementary Table S2. Table 3 Vaccine promotion behaviours and perception of having sufficient training at baseline (T0) and post-intervention (T1). CONFIVAC, 2024. Control Intervention Odds Ratios Outcome Question Response T0 n (%) T1 n (%) Change T0 n (%) T1 n (%) Change Baseline-adjusted (95% CI) Fully adjusted (95% CI) Use of presumptive communication I started vaccination conversations assuming vaccination Always 24 (36.9%) 24 (38.7%) 1.8 33 (43.4%) 52 (71.2%) 27.8 3.89 (2.46–8.40) 4.11 (1.93–9.13) Very often 34 (52.3%) 34 (54.8%) 2.5 32 (42.1%) 16 (21.9%) -20.2 ref ref Sometimes 1 (1.5%) 2 (3.2%) 1.7 2 (2.6%) 1 (1.4%) -1.3 Rarely 5 (7.7%) 0 (0%) -7.7 7 (9.2%) 4 (5.5%) -3.7 Never 0 (0%) 1 (1.6%) 1.6 2 (2.6%) 0 (0%) -2.6 DK/DA 1 (1.5%) 1 (1.6%) 0.07 0 (0%) 0 (0%) 0 Anticipate upcoming vaccines During visits when vaccines were due, I informed families about the vaccines scheduled for their upcoming visit Always 36 (55.4%) 31 (50.0%) -5.4 43 (56.6%) 53 (72.6%) 16.0 2.54 (1.14–5.85) 2.64 (1.15–6.26) Very often 17 (26.2%) 17 (27.4%) 1.3 26 (34.2%) 14 (19.2%) -15.0 ref ref Sometimes 6 (9.2%) 6 (9.7%) 0.4 3 (3.9%) 2 (2.7%) -1.2 Rarely 6 (9.2%) 7 (11.3%) 2.1 4 (5.3%) 3 (4.1%) -1.2 DK/DA 0 (0%) 1 (1.6%) 1.6 0 (0%) 1 (1.4%) 1.4 Recommend vaccination explicitly * When encountering VH families, I recommended vaccination during that same visit Always 15 (25.9%) 14 (25.5%) -0.4 22 (32.4%) 23 (34.8%) 2.5 1.98 (0.82–4.93) 2.18 (0.86–5.76) Very often 15 (25.9%) 16 (29.1%) 3.2 16 (23.5%) 24 (36.4%) 12.8 ref ref Sometimes 11 (19.0%) 6 (10.9%) -8.1 2 (2.9%) 4 (6.1%) 3.1 Rarely 8 (13.8%) 13 (23.6%) 9.8 14 (20.6%) 13 (19.7%) -0.9 Never 5 (8.6%) 5 (9.1%) 0.5 10 (14.7%) 2 (3.0%) -11.7 DK/DA 0 (0%) 1 (1.8%) 1.8 1 (1.5%) 0 (0%) -1.5 Didn't encounter a VH family 4 (6.9%) NA NA 3 (4.4%) NA NA Perception of having sufficient training I have sufficient training to address vaccination concerns Completely agree 15 (23.1%) 10 (16.1%) -6.9 13 (17.1%) 25 (34.2%) 17.1 3.96 (1.65–10.37 4.05 (1.64–10.92) Agree 34 (52.3%) 35 (56.5%) 4.1 39 (51.3%) 46 (63.0%) 11.7 ref ref Neither agree nor disagree 11 (16.9%) 13 (21.0%) 4.0 15 (19.7%) 2 (2.7%) -17.0 Disagree 5 (7.7%) 3 (4.8%) -2.9 9 (11.8%) 0 (0%) -11.8 Completely disagree 0 (0%) 1 (1.6%) 1.6 0 (0%) 0 (0%) 0 DK/DA 0 (0%) 0 (0%) 0 0 (0%) 0 (0%) 0 Notes: T0 responses are reported for all study participants (N = 141), while T1 responses include only those who completed the follow-up (n = 135). For outcomes marked with an *, responses are provided only for participants who had encountered a vaccine-hesitant family in the prior four months at T1 (control arm: n = 58 at T0, 55 at T1; intervention arm: n = 68 at T0, 66 at T1). All models were estimated by intention-to-treat. Fully adjusted models were adjusted by baseline responses, gender, occupation, region, years of work experience, and parenthood. Abbreviations: CI: confidence interval; DK/DA: don’t know/don’t answer; NA: not applicable; ref: reference; VH: vaccine hesitancy. In line with quantitative findings, focus group participants also reflected on behavioural communication changes when maintaining vaccine conversations (Table 4 ). Presumptive communication was described as a "discovery" that effectively increased vaccine acceptance, with some participants acknowledging they had previously used it but felt guilty, unaware that this approach is supported by evidence. Several participants also reported that they now anticipate upcoming vaccines, a practice some already engaged in to some extent, but not systematically. Interestingly, while none mentioned making more frequently explicit vaccine recommendations, several noted that they have implemented new tools to support their recommendations. These include sharing tailored vaccine-related information with caregivers, shifting the focus from vaccine side effects to the risks of vaccine preventable diseases, and applying a structured approach to counter misinformation and debunk myths. Tools such as asking permission to provide information or sharing personal stories (particularly in relation to their own children) were perceived as more challenging, although some informants referred using the latter with good results. Importantly, many participants reported engaging in more active listening and asking more questions to better understand the reasons behind vaccine refusal. Paediatricians also shared being more inclined to “keep the door open” in cases of persistent vaccine refusal. Focus group participants also reported feeling better prepared, which led to reduced anxiety, diminished feelings of guilt, and increased confidence. Additionally, CONFIVAC provided a greater sense of purpose and fostered empathy, enabling PHCW to recognize caregivers' doubts as legitimate and enhance communication with VH families. Table 4 Effectiveness intervention qualitative results: key themes and supporting quotes from participants. CONFIVAC, 2024 Main categories and subcategories Quotes Communication behavioural changes Use of presumptive communication The presumptive communication (...) I’ve applied it in consultation these past few weeks, and the truth is it works. It’s pretty cool. You take it for granted, most don’t question it, and you move on. (...) The presumptive communication, for me, was like the big discovery of the course. [P1] Today it’s the flu shot. And since I have adopted this attitude, a lot more people are getting vaccinated. [N2] Not feeling (...) guilt when using presumptive communication (...) Sometimes (...) it feels like I’m just getting the job done. It’s quick and straight to the point, and they say, ‘Alright.’ And I think, ‘Wow, that was fast, wasn’t it?’ ... But realizing that it’s actually a tool that works, that it’s practical and genuinely effective, has eased my mind a bit. [ Anticipate upcoming vaccines I anticipate (...), just so you know, at the next visit, there are these vaccines, which I didn’t use to mention before, but now it’s something I’ve incorporated into my daily routine. [N7] Sharing vaccine information with caregivers It has really helped me to give tools that they can read at home too, because it’s not a way of forcing them, but of giving them a little freedom to investigate on their own, and that way, when they come back, they’ve already analysed or read it, and we can discuss it again. [P8] I think this, providing examples, being able to give them scientific information is what has helped me the most. [P9] Shifting perceptions towards infection risks I didn’t do this, giving more importance to the disease, especially focusing on the risk of the pathology, rather than the vaccine. And now this is a change I’ve made. [N6] Countering misinformation I find it very interesting (...) how to debunk a false belief, and this is also very useful because it’s the way to open their eyes and maybe change things drastically. [P1] It’s been useful to know this, the impact this news can have [referring to misinformation], because I now approach it from here, like, how this information you’ve read has come to you. [N11] Asking permission to share information Perhaps the hardest thing for me is asking permission to give information. [P5] Sharing personal stories What might be harder are more personal cases. I find this a little difficult. [P3] Regarding experiences, for example, I do talk about them sometimes, right? And, for example, (…) we had a case of measles from a child who came from Barcelona and was with the grandparents. I always use this example. [P5] Concentrating efforts on hesitant caregivers Focus more on those, the ones you see are doubtful, the ones you could try to convince, and focus more on those. [P2] Keeping the door open for ongoing vaccine conversations Before, sometimes maybe you just left it there, right? They don’t want to vaccinate, fine. Now, you leave the door open. [P4] There are those who are totally opposed, (…) you know you won’t convince them, but you must leave the door open and relax a little with them (…) I tell them that if at any point they want to talk, I’m here. [P2] Active listening I didn’t listen to them as much. I mean, either I didn’t listen to them, or I probably put on a pose or something so they couldn’t explain much to me. (…) Now it’s like I’m more interested in what they’re saying. (...) listening to them more, letting them express themselves a bit, and making them feel heard, I think that’s been very good for me. [P11] And the other thing is, when there’s a ‘no’ that’s not radical, I used to ask little about why not (…). And now I do ask more, and why not? Because sometimes, if you ask why not, they give you an answer... And you say, wow, this is easy to solve, right? I can handle this one. [N2] Changes in emotional response & confidence Reduced anxiety and feelings of guilt Yes, I believe it has helped to reduce levels of (...) stress. (...) I think it has lowered a bit of this anticipatory anxiety. Then you say, well, let's see what is explained today, let's see how the conversation evolves and without blaming or anything. Well, I think this improves security, confidence, and reduces levels of stress and anxiety. [P1] And perhaps learn (...) that we shouldn't get frustrated, that another day they'll come back, the effort will be made again with those who have always been in denial. But maybe not feel frustrated and say, 'Oh no, it's your fault; you didn't manage to succeed.' (...) In the end, you end up blaming yourself. [N2] Giving value to the work Giving value to the work we do, which might be somewhat undervalued, but it’s like the act of giving a vaccine, you inject it and that’s it, but no, behind vaccines, there's a lot of psychology, a lot of emotion... like you said, because you're injecting a small child. You must use a good technique or provide good care to that child, and behind that, there are parents or a family who are scared, and all of that also reinforces everything you know, so, I give more meaning to the work I do, I give it more importance. [N7] Increased confidence I approach hesitancy, but with all the calm in the world, I mean, without worrying about having to give explanations, and now I do it with total naturalness, thinking that I’m doing it well. [N4] Above all, it’s the confidence it gives you, more confidence when, above all, the change might be the most important one: not having to think and assume that they will be vaccinated. [P3] Clearly, the emotional aspect—how we feel about this communicative work—well, in a course, you gave us skills, and I suppose that over time, as we put them into practice, we will feel more confident with the changes you’ve proposed. I think it’s still very recent, but I’m sure it’s helpful. [N8] Increased empathy Losing the fear of the situation, being able to empathize more with those people who have doubts, saying, 'Well, I mean, they have doubts, let’s see, they may be founded or not, but it’s legitimate for them to have them,' and being able to approach it from a more empathetic point of view. [P2] I think it has helped me relate to them better. Because initially, they are vaccine hesitant and I am hesitant towards anti-vaxxers, right? (...) In this aspect, it has helped me, because before I felt like I took it very personally, right? (...) It helps to normalize it, knowing that it’s a real problem, that this type of patient exists, and to be able to engage with them. [P7] Theoretical learnings Refreshing knowledge It refreshes everything about the safety and efficacy of vaccines. Of course, it’s always good to refresh it because sometimes, as a colleague said, we go into vaccination almost automatically, and we have it so clear and so internalized that many times it’s good to refresh what vaccines do. [N10] Yes, I didn’t remember learning about the composition of vaccines in university, except for the egg and the more basic things... No, I wasn’t aware of the composition of vaccines. [P10] Organisational changes Reviewing patient's vaccination history We've always done it, reviewing vaccination cards one by one. [P7] Patient recall I think we were already doing this before [referring to actively seeking patients with missed vaccines], and we’ve continued doing it. The course helps with that. [P3] Opportunistic vaccination What we've done the most is a lot, a lot, a lot of opportunistic vaccination, especially with the flu vaccine. That’s what has worked the most. [N1] After this course, we haven’t made an organizational change, but well, we already do a lot, meaning we go on catching patients who come (...) not to get vaccinated, but for other reasons. [P4] Community outreach talks Regarding what you said about giving talks, (...) we also give some talks at the nearby daycare centre. [P10] Fostering a culture of vaccination within the centre What has changed a little with the team is that now, maybe more often, we meet, discuss incidents with some families, or talk a little more about vaccines. [N11] I think what's pending, and I find it good, is involving the organization, making changes at an organizational level. To look at how we’re all doing, different professionals, even adults and paediatrics, (...) paediatrics obviously, and propose organizational changes within the team. [P9] Legend: The flow and distribution of responses between T0 and T1 are visualized, with colours representing participant responses at T1. T0 responses are shown for all study participants (N = 141), while T1 responses include only those who completed the follow-up (n = 135). For outcomes marked with an *, responses are provided only for participants who had encountered a vaccine-hesitant family in the prior four months at T1 (control arm: n = 58 at T0, 55 at T1; intervention arm: n = 68 at T0, 66 at T1). Abbreviations: DK/DA: don’t know/don’t answer; NA: not applicable; VH: vaccine hesitant. Legend: Figure A. The flow and distribution of responses from T0 to T1 are visualized, with colours denoting participant responses at T1. T0 responses are shown for all study participants (N = 141), while T1 responses include only those who completed the follow-up (n = 135). Abbreviations: NAND: neither agree nor disagree. Figure B: Each dot represents an individual participant's self-efficacy score. The boxplots illustrate the distribution of scores within each study arm Secondary outcomes related to vaccine knowledge and beliefs are reported in Supplementary Material Table S3, whereas organizational changes are reported in Supplementary Material Table S4. Although significant improvements were observed in vaccine knowledge, qualitative findings show that PHCWs felt that they already had sufficient theoretical knowledge, especially paediatricians. Nonetheless, they acknowledged the value of reviewing challenging topics, such as vaccine composition and side effects. Regarding organizational changes, we did not find a significant overall increase in the use of organizational practices to promote vaccination. Qualitative results show that many participants had already implemented some of these practices prior to the program, including reviewing vaccination history, patient recalls, and opportunistic vaccination. Process evaluation Among participants in the intervention arm, 75 (97.4%) attended the in-person session, 74 (96.1%) took the final multi-choice test, and 69 (89.6%) filled the satisfaction survey. Mean overall satisfaction was 8.7 out of 10 (SD: 0.9, range 7 to 10), all respondents (100%) would recommend the program to colleagues, and 97% found CONFIVAC quite or very applicable to their daily practice. Secondary satisfaction outcomes are summarised in Supplementary Material Figure S1 . In focus group discussions (Supplementary Material Table S5), participants emphasized the course usefulness and positively evaluated its format, materials, and contents, particularly the module on communications strategies. The asynchronous online component was appreciated for enabling flexible completion, while the in-person component was valued for the opportunity to practice theory through role-playing exercises and to share vaccine-related experiences with colleagues. Discussion We implemented and evaluated CONFIVAC, a training program designed to improve knowledge, beliefs, attitudes, self-efficacy, and vaccine-promoting behaviours among PHCWs. Four months after baseline, PHCWs in the intervention arm were significantly more likely to systematically use a presumptive communication and anticipate upcoming vaccines, but not of explicitly recommending vaccination. They also reported feeling more prepared and a higher self-efficacy in managing VH. Qualitative findings suggest that PHCWs have adopted communication tools to recommend vaccination that they perceive as effective and confidently engage in vaccine discussions with hesitant families. The program also reduced PHCW’s anxiety while increasing their empathy during these interactions. The process evaluation revealed high satisfaction with the program, which participants found both useful and applicable to their daily practice. Key effectiveness outcomes were the adoption of vaccine-promotion behaviours associated with increased vaccine acceptance, such as the use of a presumptive approach —presenting vaccines as a given rather than a choice— when initiating vaccine conversations [ 3 , 13 , 16 ]. CONFIVAC reinforced the systematic use of this approach while improving PHCWs’ confidence and reducing feelings of guilt when using it. In addition, it also improved the behaviour of anticipating future vaccinations. This primes individuals by reinforcing vaccination as a default behaviour and a societal norm, keeping it present in their minds, and potentially predisposing them to seek information, thereby facilitating open communication channels between families and PHCWs [ 26 ]. A strong provider recommendation is another well-established effective strategy for increasing vaccination [ 13 ]. While the difference in systematically making an explicit vaccine recommendation in cases of VH was not statistically significant between study arms, this might be due to the small sample size and the fact that PHCWs may view recommending vaccines as a "default" behaviour, making explicit recommendations less salient. Qualitative findings support this idea, as PHCWs did not specifically mention explicit recommendations during discussions, despite reporting successful examples of their use of tools introduced by CONFIVAC to strengthen vaccine recommendations. Interestingly, the proportion of participants that “very often” make explicit vaccine recommendations increased 13% in the intervention arm (compared to 3% in the control arm), suggesting that indeed the intervention had some effect. Finally, CONFIVAC significantly increased PHCWs' perception of having sufficient training to address VH, effectively meeting a training gap previously identified worldwide [ 6 , 18 , 19 ]. This is particularly important, as prior studies have underscored the need for targeted interventions to equip healthcare providers with the necessary skills and knowledge to effectively manage VH [ 6 , 27 – 30 ]. Evidence supporting educational interventions to address VH remains limited, particularly outside the United States [ 29 – 31 ]. A 2018 Cochrane systematic review found low- to moderate-certainty evidence that education-based interventions for caregivers increase childhood vaccination rates, with even less certainty regarding their effectiveness for VH families [ 31 ]. Similarly, interventions that focus on increasing theoretical vaccine knowledge among PHCWs seem to have minimal impact on vaccination uptake, despite increasing PHCWs’ self-confidence [ 3 , 30 ]. In contrast, CONFIVAC emphasizes how to deliver vaccine-related messages, rather than just focusing on what to communicate. This approach is consistent with the findings from two systematic reviews on effective interventions to address VH and increase vaccine uptake [ 29 , 30 ], which underscore the importance of communication training. However, previous interventions varied in scope in scope and used different evaluation methods, often lacking a control group, making direct comparisons with our results challenging [ 20 , 29 ]. Commonly used communication strategies in these interventions were the use of presumptive communication and motivational interviewing (MI), either alone or in combination [ 32 – 34 ], both of which have shown to increase vaccine uptake [ 3 , 16 , 29 , 35 ]. CONFIVAC follows this trend, while also extending its scope by offering a wider range of additional communication tools, such as making strong vaccine recommendations, tailoring vaccine-related messages to caregivers needs, sharing personal stories, or debunking myths when needed while avoiding a backfire effect [ 3 , 12 , 16 ]. In addition to educational interventions, organizational strategies have also proven effective in increasing vaccine uptake [12, 26, 36], and may also reduce the individual burden of vaccine-related tasks by streamlining workflows and promoting shared responsibilities [37]. Thus CONFIVAC also includes a module on organizational practices both within consultations (e.g., reviewing immunization records, anticipating vaccines, opportunistic vaccination) and across PHC teams (e.g., reminders, recalls, and school vaccination efforts) to foster a vaccination culture. However, many of these strategies were already partially established prior to CONFIVAC. For example, in Catalonia PHC teams use a shared electronic health records system with an integrated vaccine register that facilitates reviewing a patient’s immunization status, flags missed vaccines and proposes future ones. In addition, vaccine uptake objectives among PHCWs are linked to economic incentives, standing orders allow nurses to administer routine vaccines without individual physician approval, vaccines for school-age children are delivered at schools, and text messaging campaigns are occasionally used. Therefore, CONFIVAC’s primary focus was to equip PHCWs with the skills to reinforce and consistently utilize these existing tools, while introducing adaptable practices for specific contexts, rather than pursuing a broad organizational redesign. Thus, the absence of statistically significant changes in organizational practices probably reflects their pre-existing implementation, as corroborated by focus group discussions. Additionally, the post-intervention measurement period may have been too short to detect meaningful changes. Finally, we also acknowledge that training PHCWs alone may be insufficient for broader organizational changes, which often require additional resources and structural support. Another key finding of our study is the increase in self-efficacy to handle VH, consistent with previous studies on vaccine-related educational interventions for healthcare workers [ 16 , 17 , 29 ]. Given that self-efficacy has been shown to be associated with vaccine recommendations and acceptance [ 27 ], this improvement is significant. Participants also reported feeling less anxious and experiencing a greater sense of accomplishment. This is particularly relevant given that PHCWs often feel emotional distress when dealing with VH situations [ 20 ]. A recent scoping review highlighted that many existing interventions fail to address the emotional burden associated with these encounters, leaving healthcare workers unprepared to manage their own feelings effectively [ 20 ]. To bridge this gap, our intervention included a dedicated module on emotional management, equipping PHCWs with tools for self-monitoring and regulation during challenging consultations. These findings highlight the importance of addressing both vaccination-related and PHCW’s emotional well-being [16, 38]. The major strength of this study lies in its robust evaluation, which employed a mixed-methods design combining a cluster-randomized clinical trial with a qualitative study. Additionally, CONFIVAC was developed using a grounded methodology (Intervention Mapping)[39] and included inputs from paediatric practitioners, ensuring its alignment with real-world healthcare needs. Relevance and timeliness are further demonstrated by the high prevalence of VH in our setting, with 90% of participants reporting recent encounters with VH families. Addressing such a widespread issue, alongside the involvement of paediatric practitioners, likely contributed to CONFIVAC’s successful implementation, which was marked by high levels of satisfaction, perceived usefulness, and strong adoption rates. These outcomes highlight the program’s practical value and reinforce its strength as a context-responsive intervention. Moreover, CONFIVAC fills a critical gap in the literature, as few interventions targeting VH have been conducted and evaluated with control groups and using a mixed methods design in European countries. Another key strength of CONFIVAC is its comprehensive scope. The program covers a broad range of training content, including theoretical knowledge, communication skills, and organizational strategies. It is also inclusive in its approach, targeting both nurses and physicians, and focuses on systematic vaccines rather than a single vaccine. The program’s hybrid format is another significant advantage. The online training component enhances accessibility and sustainability [ 11 ], while the two-hour in-person session—featuring activities such as role-playing—are likely to increase effectiveness, as supported by previous evidence [ 29 ]. However, this study has also limitations. First, the sample size was small, and the follow-up period was limited to four months after the baseline, and in some cases, just one month after the end of the intervention. This short timeframe may hinder the possibility to observe certain changes or to fully assess the program's long-term effects. Second, social desirability bias (i.e., participants overreporting positive outcomes) could also affect the validity of the results. Third, outcomes were measured among providers rather than caregivers, meaning that changes in providers' practices were not assessed from the caregivers' perspective, and the intervention’s impact was not assessed at the family level. Additionally, no data were collected on vaccine coverage, so the direct impact of the program on vaccination uptake remains unknown. While this was not an objective of the current study, we plan to explore the impact of CONFIVAC on vaccine coverage in the future. However, previous evidence suggests that communication-focused interventions can improve vaccine uptake and reduce vaccine hesitancy among caregivers [ 13 , 15 , 29 ]. Conclusion CONFIVAC, a comprehensive training program for PHCWs encompassing vaccine knowledge, communication skills, and organizational tools, was associated with short-term improvements in vaccine-promoting behaviours, self-efficacy in addressing VH, and vaccine-related knowledge. Additionally, it had a positive impact on PHCWs' emotional well-being, an area underexplored in the literature. This study underscores the value of targeted, accessible, and behavioural models-based training programs in enhancing healthcare workers' skills and confidence in promoting vaccines. Abbreviations VH: vaccine hesitancy; PHCW: paediatric healthcare worker; PPH: primary paediatric healthcare; SD: standard deviation Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the Drug Research Ethics Committee Parc de Salut MAR (CEIm-PSMAR)( 2021/9729/I) and by IDIAP Jordi Gol Clinical Research Ethics Committee (CEIm)(22/194-P). Consent for publication Not aplicable. Availability of data and materials The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding This work was supported by Fondo de Investigaciones Sanitarias from Instituto de Salud Carlos III (ISCIII), Ministry of Science and Innovation, Spain, through the Health Research Projects (AES 2021) program and cofunded by the European Union, grant no. PI21/01710. Authors' contributions ED, SV, VP, AA, EH, and ER conceptualized the study and developed the methodology, with valuable contributions from XB. ED, SV, EH, ER, and ARM oversaw project administration. ED secured funding and supervised the work. ER, EH, SV, AA, and VP analyzed and interpreted the data. ER drafted the initial manuscript with insightful contributions from AA, SV, VP, EH, and ED. All authors contributed to manuscript review and editing and read and approved the final manuscript. Acknowledgements We would like to acknowledge the feedback provided by Anna Borja, Anna Gatell, Anna Ramon, Àurea Arce, Blanca Macias, Claudia Solito, Ester Mateus, Maria Arranz, Maria Esther Isern, María García, Maria Pueyo, Mireia Biosca, Mireia Garcia, Montserrat Guarido, Montserrat Melo, Noelia González, Pepe Serrano, Ramon Capdevila, Raquel Muñoz, Roger Benavent, Nieves Barragán, and Marina Prades who supported the development of the training program materials and questionnaires. We also thank Ricard Codina for his support with the online platform and Asunción Martínez for directing the video cases. We are also grateful to the volunteers who performed as actors and actresses in the video cases—Anna Pérez, Cristina Delgado, Étienne Pagès, Guillem Albornà, Itziar Falcón, Ivan Martí, Maira Carolina Guzmán, Manon Pueller, Sandra Cuspinera, and Sonia Gil. Additionally, we acknowledge Beatriz Román for lending her voice to the materials. Members of the CONFIVAC Research Group Marta Cabanas g , Carmen Gallego h , Usue Elizondo-Alzola i , David Palma c,j , Camila A Picchio k , Gemma Ricós, l,m Paula Santià a,h , Josep Vidal-Alaball d,n,o a Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain c CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, C/Monforte de Lemos 3-5. Pabellón 11, 28029, Madrid, Spain d Unitat de Recerca i Innovació, Gerència d'Atenció Primària i a la Comunitat de la g Directora de Sectors Sanitaris, AIS Barcelona Litoral Mar, Consorci Sanitari de Barcelona, Spain h Unitat de Metodologia, Qualitat i Avaluació Assistencial, Gerència d’Atenció Primària i a la Comunitat Delta, Institut Català de la Salut, Barcelona, Spain i Farmacia de Atención Primaria, Osakidetza-Sevicio Vasco de Salud (OSI Debagoiena), Avd. Nafarroa, 16, 20500, Gipuzkoa, Spain j Department of International Health, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands k Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain l Institut Català de la Salut, Gran Via de les Corts Catalanes 587, 08007, Barcelona, Spain m Departament de Salut, Travessera de les Corts, 131, 159, Les Corts, 08028, Barcelona, Spain n Intelligence for Primary Care Research Group, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Manresa, Spain o Department of Medicine, Faculty of Medicine, University of Vic-Central, University of Catalonia, Vic, Spain References World Health Organization. Ten threats to global health in 2019. 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019. Accessed 3 Oct 2024. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. 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Communication Skills Training for Physicians Improves Patient Satisfaction. J Gen Intern Med. 2016;31:755. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH, & Schaalma H, Markham C, et al. Planning health promotion programs: An intervention mapping approach. 2nd edition. Jossey-Bass/Wiley; 2006. Additional Declarations No competing interests reported. Supplementary Files SupplementaryBMCpublic.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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EAP Baix Berguedà","correspondingAuthor":false,"prefix":"","firstName":"Xavier","middleName":"","lastName":"Bruna","suffix":""},{"id":418717212,"identity":"e87c0f9a-11b7-42fb-8b99-177209347258","order_by":7,"name":"M Isabel Pasarín","email":"","orcid":"","institution":"Barcelona Public Health Agency. Pl. Lesseps","correspondingAuthor":false,"prefix":"","firstName":"M","middleName":"Isabel","lastName":"Pasarín","suffix":""},{"id":418717213,"identity":"44f495e7-d887-4be5-b470-078330ec25be","order_by":8,"name":"Cristina Rius","email":"","orcid":"","institution":"Barcelona Public Health Agency. Pl. Lesseps","correspondingAuthor":false,"prefix":"","firstName":"Cristina","middleName":"","lastName":"Rius","suffix":""},{"id":418717214,"identity":"a46e575f-661a-422f-8f23-0099f2f99437","order_by":9,"name":"Elia Díez","email":"","orcid":"","institution":"Barcelona Public Health Agency. Pl. Lesseps","correspondingAuthor":false,"prefix":"","firstName":"Elia","middleName":"","lastName":"Díez","suffix":""},{"id":418717215,"identity":"f03bc1c1-daf5-4736-9fc9-02f0c10073ba","order_by":10,"name":"CONFIVAC Research Group","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"CONFIVAC","middleName":"Research","lastName":"Group","suffix":""}],"badges":[],"createdAt":"2025-02-13 08:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6021302/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6021302/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77292062,"identity":"9f176b06-096c-471c-a748-102ad3487953","added_by":"auto","created_at":"2025-02-27 06:49:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":135864,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart. CONFIVAC, 2024\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6021302/v1/36e31529e8da38cdc87fc1b5.png"},{"id":77293942,"identity":"789a89ae-3b47-48ae-85e8-3f9f8b635554","added_by":"auto","created_at":"2025-02-27 07:04:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":362225,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in vaccine promotion behaviours from baseline (T0) to post-intervention (T1). CONFIVAC, 2024\u003c/p\u003e\n\u003cp\u003eLegend: The flow and distribution of responses between T0 and T1 are visualized, with colours representing participant responses at T1. T0 responses are shown for all study participants (N= 141), while T1 responses include only those who completed the follow-up (n=135). For outcomes marked with an *, responses are provided only for participants who had encountered a vaccine-hesitant family in the prior four months at T1 (control arm: n = 58 at T0, 55 at T1; intervention arm: n = 68 at T0, 66 at T1). Abbreviations: DK/DA: don’t know/don’t answer; NA: not applicable; VH: vaccine hesitant.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6021302/v1/104dfedb7e2411c16010256c.png"},{"id":77292063,"identity":"911fdb0c-5dd7-45d1-ab59-f50eb897fbba","added_by":"auto","created_at":"2025-02-27 06:49:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":205996,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in perception of having sufficient training and self-efficacy to handle vaccine hesitancy from baseline (T0) to post-intervention (T1). CONFIVAC, 2024.\u003c/p\u003e\n\u003cp\u003eLegend: Figure A. The flow and distribution of responses from T0 to T1 are visualized, with colours denoting participant responses at T1. T0 responses are shown for all study participants (N = 141), while T1 responses include only those who completed the follow-up (n = 135). Abbreviations: NAND: neither agree nor disagree. Figure B: Each dot represents an individual participant's self-efficacy score. The boxplots illustrate the distribution of scores within each study arm\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6021302/v1/bd7cf25539e859e1bd523617.png"},{"id":77295537,"identity":"3231ba76-dcc6-4b30-9c5a-9ff39b89ebd7","added_by":"auto","created_at":"2025-02-27 07:12:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1999275,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6021302/v1/9dba259b-6e42-420a-b698-3b2b1aac2243.pdf"},{"id":77292046,"identity":"b4cb1866-c118-4bfa-ad8f-e3dfe55dba0c","added_by":"auto","created_at":"2025-02-27 06:48:57","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":489321,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryBMCpublic.docx","url":"https://assets-eu.researchsquare.com/files/rs-6021302/v1/7875e1937e60f9b00f3b9e59.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of CONFIVAC, an intervention to enhance Paediatric Nurses and Paediatricians skills to promote vaccination: a mixed-methods cluster randomised clinical trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVaccine hesitancy (VH) is one of the top ten threats to global health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. VH, defined as the delay or refusal to accept vaccines despite their availability, is a complex phenomenon that can manifest in varying degrees of indecision or refusal regarding some or all vaccines [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although vaccination is one of the most cost-effective measures in public health [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], misinformation and anti-vaccine discourses are on the rise across social media platforms, a trend further amplified by the COVID-19 pandemic [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This might have contributed to declining public confidence in vaccines in Europe in recent years [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost vaccines are administered during childhood following national immunisation schedules [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Primary paediatric healthcare workers (PHCW), including nurses and paediatricians, are primarily responsible for promoting these vaccines and play a critical role in influencing parental decisions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the manner in which PHCWs convey vaccination recommendations can significantly affect vaccine acceptance [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Up-to-date vaccine knowledge, along with strong communication and organisational strategies, are essential for building trust with caregivers and promoting vaccination [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Many PHCWs, however, might feel unprepared to effectively handle families\u0026rsquo; vaccination doubts [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A study conducted in Barcelona, Spain, revealed that 30% of PHCWs felt they lacked adequate information and training to effectively address families' concerns, while over half expressed a desire for more vaccine-related information [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile some interventions have aimed to train PHCWs in addressing VH, most have been limited in scope. Predominantly conducted in the US, these interventions typically focus on theoretical knowledge, communication skills, or a combination of both, target mainly physicians, and are often limited to a single vaccine (e.g., influenza)[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Moreover, they tend to overlook the emotional burden experienced by PHCWs when addressing VH. To address these limitations, we developed CONFIVAC, an intervention based in behavioural theories, models, and frameworks designed to enhance PHCW\u0026rsquo;s attitudes, skills and behaviours in promoting vaccination [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. CONFIVAC comprises ten hours of asynchronous theoretical online training followed by two hours of in-person practical training featuring role-playing exercises. The program is built on three key pillars: 1) reinforcing knowledge about vaccines and countering misinformation; 2) building evidence-based communication skills to promote vaccination and address VH in consultations; and 3) learning and implementing organisational strategies to promote vaccination within paediatric consultations and healthcare teams. A detailed study protocol including a comprehensive description of the program design, content, and evaluation plan, is available elsewhere [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2023\u0026ndash;2024, we implemented CONFIVAC among PHCWs working in two northeastern regions of Spain, Barcelona city and Central Catalonia. The aim of this study is to evaluate the effectiveness of CONFIVAC in improving knowledge, beliefs, self-efficacy and vaccine-promoting behaviours as well as to assess the implementation process using a mixed methods evaluation design.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eWe conducted a mixed-methods study, including a two-arm parallel cluster randomised controlled trial targeting PHCWs in Barcelona city and Central Catalonia alongside a qualitative study from a phenomenological perspective.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted between October 2023 and February 2024 in Barcelona and Central Catalonia. Spain has a free, public health system in which systematic childhood vaccines are mostly delivered as part of routine care provided by public primary paediatric healthcare (PPH) teams, who serve the population living within their assigned territorial areas. In 2023, Barcelona had 41 PPH teams, with approximately 340 PHCW serving 194,000 children whereas Central Catalonia had 38 PPH teams, with approximately 110 PHCW serving 76,000 children across both rural and urban areas.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eThe inclusion criteria were being a paediatrician or paediatric nurse from a PPH team in Barcelona or Central Catalonia. The exclusion criteria were having previously participated in the design of the intervention or being a resident (either medical or nursing) due to their status as temporary staff in training programs\u003c/p\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003e We invited all PHCWs from PPH teams in Barcelona and Central Catalonia through email invitations that included a brochure summarising the research project, the contents of the free training program, and the incentives for participation, which included 2.5 educational credits and a certificate of participation in research. Email invitations were distributed hierarchically, starting with the heads of paediatrics in each region, followed by PPH team directors, and then forwarded to PHCWs within each PPH team. We also conducted an online information session. PHCWs interested in joining the study were pre-enrolled by completing a brief online form, accessible through the brochure. The flowchart of the study is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 174 potential participants were assessed for eligibility. Two were excluded for not meeting inclusion criteria: one was a dentist, and the other was a nurse working exclusively in adult care.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eAssignment of intervention\u003c/h3\u003e\n\u003cp\u003eTo minimise contamination, we used cluster randomisation. A total of 29 PPH teams from Barcelona and 26 PPH teams from Central Catalonia (i.e., the teams from PHCW pre-enrolled) were paired according to the total population served, socioeconomic status, vaccination coverage, and region (Barcelona or Central Catalonia). Within each pair, individuals were randomly assigned to one of the two parallel arms: intervention or control arm (standard care). The intervention arm received the intervention from October 2023 to February 2024 (autumn course edition), whereas the control arm was offered the course for ethical reasons after data collection had ended, from February 2024 to June 2024 (spring edition). Prior to enrolment PHCWs were informed that they could neither choose nor know their assigned course edition before baseline data collection. Following randomisation, participants were granted access to the online learning platform (Moodle). Enrolment was completed upon reviewing the participant information sheet and providing signed informed consent on the platform.\u003c/p\u003e \u003cp\u003e Out of the 172 individuals who were cluster-randomized, 142 participants signed the informed consent. Of these,77 were assigned to the intervention arm (from 29 PPH teams) and 65 to the control arm (from 25 PPH teams). The imbalance by study arm in participant and team allocation numbers was due to variations in enrolment completion rates and the number of participants per team (median of 2 per team, range from 1 to 10).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eParticipants filled a questionnaire at baseline (T0) and again four months later (T1). The online training was available from October to December 2023, while group in-person training sessions \u0026mdash;conducted in small groups\u0026mdash; took place in January 2024. At least one-month elapsed between the last in-person session and T1. The questionnaire was developed ad hoc using items from previously validated questionnaires to assess changes in the identified psychosocial determinants of vaccination and was pre-tested and pilot tested [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. PHCWs\u0026rsquo; knowledge and beliefs about the safety and effectiveness of childhood vaccines, self-efficacy in managing vaccine hesitancy, frequency of vaccine promotion behaviours during paediatric visits, and perception of having sufficient training to address VH were measured using five-point Likert questions. The use of organisational tools within paediatric visits and at the PPH team level were as well as sociodemographic information (age, sex, role, years of practice, and parenthood) were also collected. Participants in the intervention arm were also asked to fill a satisfaction survey at the end of the training program. Both questionnaires can be consulted in the study protocol [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eKey effectiveness outcomes included the frequency of vaccine promoting behaviours (use of presumptive communication, anticipate upcoming vaccines, recommend vaccination explicitly in cases of VH) measured on a scale ranging from \u0026ldquo;Never\u0026rdquo; to \u0026ldquo;Always\u0026rdquo;, and the perception of having sufficient training to address VH, measured on a scale from \u0026ldquo;Completely disagree\u0026rdquo; to \u0026ldquo;Completely agree\u0026rdquo;.\u003c/p\u003e \u003cp\u003eAs a secondary outcome, we assessed self-efficacy in managing vaccine-hesitancy using a 17-item questionnaire with responses recorded on a five-point Likert scale ranging from \"Very incapable\" (0 points) to \"Very capable\" (3 points), yielding a total score range from 0 to 68 points. Higher scores indicate greater self-efficacy. We also reported as secondary outcomes the remaining aspects assessed in the questionnaire: vaccine-related knowledges and beliefs, and the use of organizational tools to promote vaccination within primary teams.\u003c/p\u003e \u003cp\u003eMain process outcomes included overall satisfaction (rated on a 0\u0026ndash;10 scale), likelihood of recommending CONFIVAC to a colleague (yes/no), and perceived applicability of the training (measured on a five-point Likert scale ranging from \u0026ldquo;A lot\u0026rdquo; to \u0026ldquo;Very little\u0026rdquo;). Secondary outcomes comprised the remaining items included in the satisfaction survey.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe described participant\u0026rsquo;s baseline demographic characteristics as well as main and secondary effectivity outcomes at baseline (T0) and post-intervention (T1) by allocation arm. We also described the results of the satisfaction survey. Categorical variables were summarised using counts and percentages, while continuous variables were described using means with standard deviations (SD). Differences in self-efficacy scores between the two arms at T0 and T1 were compared using a t-test, with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eTo assess the intervention's effectiveness, we initially planned to estimate multi-level ordinal logistic regression models. However, due to insufficient observations at certain levels (i.e., several PPH teams had only one participant) and the violation of the proportional odds assumption, we performed single-level logistic regression models. Outcomes were dichotomised as 0/1, where 1 represented the most favourable response category (e.g., \u003cem\u003eAlways\u003c/em\u003e for behaviour-related outcomes). This decision was based on a preliminary analysis of data at T0, which revealed that participants had already a high baseline level across most outcomes. Odds Ratios were estimated along with 95% confidence intervals. We estimated baseline-adjusted models (adjusting for values at T0) as well as fully adjusted models (adjusting for values at T0, gender, parenthood status, occupation, years of professional practice, and region). Logistic regressions were performed on an intention-to-treat basis, with participants lost to follow-up being assigned their baseline values at T1. All analyses were conducted using R software (version 4.3.0).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eQualitative study\u003c/h2\u003e \u003cp\u003eA qualitative phenomenological study was designed to evaluate both the effectiveness and the process, based on participants' perceptions. The sample was intentionally designed among the intervention arm participants using predefined profiles to ensure diversity in gender, experience, rurality, parenthood, socioeconomic status, exam attempts, and satisfaction. To encourage participation, a small economic incentive was provided in the form of a gift card. Final sample consisted of 26 PHCWs, who participated in 4 focus groups (2 with paediatricians and 2 with nurses). Focus groups were held online via Teams in March 2024, with 6 to 8 participants per group and lasted 1.5 to 2 hours. A topic guide was developed to structure the discussion (Supplementary Material 1). Sessions were recorded with participant consent and transcribed using Turboscribe. The transcriptions were subsequently reviewed by the research team.\u003c/p\u003e \u003cp\u003eWe conducted a thematic content analysis [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], with the support of the software ATLAS.ti version 24.1. Themes were coded and classified, identifying common patterns as well as convergences and divergences in the data. Analytical categories were derived from the topic guide and through constant comparison of the data. To ensure the quality of the information, the data were triangulated among the research team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki and approved by the Drug Research Ethics Committee Parc de Salut MAR (CEIm-PSMAR)( 2021/9729/I) and by IDIAP Jordi Gol Clinical Research Ethics Committee (CEIm)(22/194-P). This study was registered on 5th July 2024 at ClinicalTrials.gov under the ID NCT06489236.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline characteristics of participants were similar in both study arms (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most participants were women (93.0%), nurses (66.9%), had children (75.4%), and had encountered VH families in the prior 4 months (90.8%). Participants were evenly distributed by region, with 56.3% being from Barcelona. Seven participants were lost to follow-up, with baseline characteristics similar to those who completed the study (Supplementary Material Table\u0026nbsp;1). One participant was excluded from the analyses due to responding \u003cem\u003edo not know\u003c/em\u003e to all items. A description of the characteristics of PHCWs that participated in the qualitative study can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of study participants. CONFIVAC, 2024.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.8 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.7 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (92.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.289\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenthood, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (78.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.552\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.285\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of work experience, \u003c/p\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.6 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.1 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEncountered a vaccine hesitant family in the prior 4 months at baseline, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (92.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLost to follow-up, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNotes: p-values were calculated using Student's t-tests for continuous variables and chi-square tests for categorical variables. Vaccine hesitant families include those who had doubts about vaccines. Abbreviations: SD: standard deviation.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants in focus group discussions. CONFIVAC, 2024\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYears of professional experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOverall satisfaction (0\u0026ndash;10)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCentral Catalonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatrician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarcelona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness evaluation\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eBehavioural changes\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrate changes in vaccine promotion behaviours from T0 to T1. The proportion of participants who always initiate vaccination conversations using presumptive communication increased by 28% in the intervention arm (43\u0026ndash;71%) compared to a 2% increase in the control arm (37\u0026ndash;39%). Similarly, the proportion of participants who always anticipate upcoming vaccines increased by 16% in the intervention arm (57\u0026ndash;73%) while it decreased by 5% in the control arm (55\u0026ndash;50%). The proportion of participants who always explicitly recommend vaccination in cases of VH increased slightly by 3% in the intervention arm (32\u0026ndash;35%) compared to no change in the control arm (26% at both time points). These differences were statistically significant for presumptive communication [aOR: 4.05 (95% CI: 1.64\u0026ndash;10.92)] and anticipating upcoming vaccines [aOR: 2.64 (95% CI: 1.15\u0026ndash;6.26)] but not for explicitly recommending vaccination [aOR: 2.18 (95% CI: 0.86\u0026ndash;5.76)]. Changes in perception of having sufficient training and self-efficacy to handle VH are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The proportion of participants who completely agreed they had sufficient training to address vaccination concerns increased by 17% in the intervention arm (17\u0026ndash;34%) and decreased by 7% in the control arm (23\u0026ndash;16%). This difference was statistically significant [aOR: 4.05 (95% CI: 1.64\u0026ndash;10.92)]. In terms of self-efficacy, both arms had similar scores at T0, with a mean (SD) score of 52.5 (7.9) for the control arm and 52.9 (8.1) for the intervention arm (p\u0026thinsp;=\u0026thinsp;0.74). By T1, the score remained stable in the control arm (mean: 51.6 [9.1]) whereas it increased in the intervention arm to 57.1 (8.3). The mean difference between the two arms at T1 was 5.5 points, with a 95% confidence interval of 2.6 to 8.5 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Responses to the self-efficacy score questionnaire are reported in Supplementary Table S2.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVaccine promotion behaviours and perception of having sufficient training at baseline (T0) and post-intervention (T1). CONFIVAC, 2024.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eOdds Ratios\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eQuestion\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eResponse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eT0\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eT1\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eChange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eT0\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eT1\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eChange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eBaseline-adjusted\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eFully adjusted\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eUse of presumptive communication\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eI started vaccination conversations assuming vaccination\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (36.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (38.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33 (43.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52 (71.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.89 (2.46\u0026ndash;8.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.11 (1.93\u0026ndash;9.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (52.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (54.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (42.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 (21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-20.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDK/DA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eAnticipate upcoming vaccines\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eDuring visits when vaccines were due, I informed families about the vaccines scheduled for their upcoming visit\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (55.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43 (56.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53 (72.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.54 (1.14\u0026ndash;5.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.64 (1.15\u0026ndash;6.26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (26.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (27.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26 (34.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (19.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (11.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDK/DA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eRecommend vaccination explicitly *\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eWhen encountering VH families, I recommended vaccination during that same visit\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23 (34.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.98 (0.82\u0026ndash;4.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.18 (0.86\u0026ndash;5.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (29.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (19.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (10.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (13.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (23.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (20.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDK/DA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDidn't encounter a VH family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003ePerception of having sufficient training\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eI have sufficient training to address vaccination concerns\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompletely agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25 (34.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.96 (1.65\u0026ndash;10.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.05 (1.64\u0026ndash;10.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (52.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39 (51.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46 (63.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeither agree nor disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (21.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-17.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompletely disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDK/DA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003cem\u003eNotes: T0 responses are reported for all study participants (N\u0026thinsp;=\u0026thinsp;141), while T1 responses include only those who completed the follow-up (n\u0026thinsp;=\u0026thinsp;135). For outcomes marked with an *, responses are provided only for participants who had encountered a vaccine-hesitant family in the prior four months at T1 (control arm: n\u0026thinsp;=\u0026thinsp;58 at T0, 55 at T1; intervention arm: n\u0026thinsp;=\u0026thinsp;68 at T0, 66 at T1). All models were estimated by intention-to-treat. Fully adjusted models were adjusted by baseline responses, gender, occupation, region, years of work experience, and parenthood.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003cem\u003eAbbreviations: CI: confidence interval; DK/DA: don\u0026rsquo;t know/don\u0026rsquo;t answer; NA: not applicable; ref: reference; VH: vaccine hesitancy.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn line with quantitative findings, focus group participants also reflected on behavioural communication changes when maintaining vaccine conversations (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Presumptive communication was described as a \"discovery\" that effectively increased vaccine acceptance, with some participants acknowledging they had previously used it but felt guilty, unaware that this approach is supported by evidence. Several participants also reported that they now anticipate upcoming vaccines, a practice some already engaged in to some extent, but not systematically. Interestingly, while none mentioned making more frequently explicit vaccine recommendations, several noted that they have implemented new tools to support their recommendations. These include sharing tailored vaccine-related information with caregivers, shifting the focus from vaccine side effects to the risks of vaccine preventable diseases, and applying a structured approach to counter misinformation and debunk myths. Tools such as asking permission to provide information or sharing personal stories (particularly in relation to their own children) were perceived as more challenging, although some informants referred using the latter with good results. Importantly, many participants reported engaging in more active listening and asking more questions to better understand the reasons behind vaccine refusal. Paediatricians also shared being more inclined to \u0026ldquo;keep the door open\u0026rdquo; in cases of persistent vaccine refusal. Focus group participants also reported feeling better prepared, which led to reduced anxiety, diminished feelings of guilt, and increased confidence. Additionally, CONFIVAC provided a greater sense of purpose and fostered empathy, enabling PHCW to recognize caregivers' doubts as legitimate and enhance communication with VH families.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffectiveness intervention qualitative results: key themes and supporting quotes from participants. CONFIVAC, 2024\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain categories and subcategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCommunication behavioural changes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of presumptive communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eThe presumptive communication (...) I\u0026rsquo;ve applied it in consultation these past few weeks, and the truth is it works. It\u0026rsquo;s pretty cool. You take it for granted, most don\u0026rsquo;t question it, and you move on. (...) The presumptive communication, for me, was like the big discovery of the course. [P1]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eToday it\u0026rsquo;s the flu shot. And since I have adopted this attitude, a lot more people are getting vaccinated. [N2]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNot feeling (...) guilt when using presumptive communication (...) Sometimes (...) it feels like I\u0026rsquo;m just getting the job done. It\u0026rsquo;s quick and straight to the point, and they say, \u0026lsquo;Alright.\u0026rsquo; And I think, \u0026lsquo;Wow, that was fast, wasn\u0026rsquo;t it?\u0026rsquo; ... But realizing that it\u0026rsquo;s actually a tool that works, that it\u0026rsquo;s practical and genuinely effective, has eased my mind a bit. [\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticipate upcoming vaccines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eI anticipate (...), just so you know, at the next visit, there are these vaccines, which I didn\u0026rsquo;t use to mention before, but now it\u0026rsquo;s something I\u0026rsquo;ve incorporated into my daily routine. [N7]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSharing vaccine information with caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eIt has really helped me to give tools that they can read at home too, because it\u0026rsquo;s not a way of forcing them, but of giving them a little freedom to investigate on their own, and that way, when they come back, they\u0026rsquo;ve already analysed or read it, and we can discuss it again. [P8]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eI think this, providing examples, being able to give them scientific information is what has helped me the most. [P9]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShifting perceptions towards infection risks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eI didn\u0026rsquo;t do this, giving more importance to the disease, especially focusing on the risk of the pathology, rather than the vaccine. And now this is a change I\u0026rsquo;ve made. [N6]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountering misinformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eI find it very interesting (...) how to debunk a false belief, and this is also very useful because it\u0026rsquo;s the way to open their eyes and maybe change things drastically. [P1]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIt\u0026rsquo;s been useful to know this, the impact this news can have [referring to misinformation], because I now approach it from here, like, how this information you\u0026rsquo;ve read has come to you. [N11]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsking permission to share information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePerhaps the hardest thing for me is asking permission to give information. [P5]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSharing personal stories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWhat might be harder are more personal cases. I find this a little difficult. [P3]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eRegarding experiences, for example, I do talk about them sometimes, right? And, for example, (\u0026hellip;) we had a case of measles from a child who came from Barcelona and was with the grandparents. I always use this example. [P5]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcentrating efforts on hesitant caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFocus more on those, the ones you see are doubtful, the ones you could try to convince, and focus more on those. [P2]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeeping the door open for ongoing vaccine conversations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eBefore, sometimes maybe you just left it there, right? They don\u0026rsquo;t want to vaccinate, fine. Now, you leave the door open. [P4]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eThere are those who are totally opposed, (\u0026hellip;) you know you won\u0026rsquo;t convince them, but you must leave the door open and relax a little with them (\u0026hellip;) I tell them that if at any point they want to talk, I\u0026rsquo;m here. [P2]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive listening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eI didn\u0026rsquo;t listen to them as much. I mean, either I didn\u0026rsquo;t listen to them, or I probably put on a pose or something so they couldn\u0026rsquo;t explain much to me. (\u0026hellip;) Now it\u0026rsquo;s like I\u0026rsquo;m more interested in what they\u0026rsquo;re saying. (...) listening to them more, letting them express themselves a bit, and making them feel heard, I think that\u0026rsquo;s been very good for me. [P11]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAnd the other thing is, when there\u0026rsquo;s a \u0026lsquo;no\u0026rsquo; that\u0026rsquo;s not radical, I used to ask little about why not (\u0026hellip;). And now I do ask more, and why not? Because sometimes, if you ask why not, they give you an answer... And you say, wow, this is easy to solve, right? I can handle this one. [N2]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChanges in emotional response \u0026amp; confidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced anxiety and feelings of guilt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes, I believe it has helped to reduce levels of (...) stress. (...) I think it has lowered a bit of this anticipatory anxiety. Then you say, well, let's see what is explained today, let's see how the conversation evolves and without blaming or anything. Well, I think this improves security, confidence, and reduces levels of stress and anxiety. [P1]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAnd perhaps learn (...) that we shouldn't get frustrated, that another day they'll come back, the effort will be made again with those who have always been in denial. But maybe not feel frustrated and say, 'Oh no, it's your fault; you didn't manage to succeed.' (...) In the end, you end up blaming yourself. [N2]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGiving value to the work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGiving value to the work we do, which might be somewhat undervalued, but it\u0026rsquo;s like the act of giving a vaccine, you inject it and that\u0026rsquo;s it, but no, behind vaccines, there's a lot of psychology, a lot of emotion... like you said, because you're injecting a small child. You must use a good technique or provide good care to that child, and behind that, there are parents or a family who are scared, and all of that also reinforces everything you know, so, I give more meaning to the work I do, I give it more importance. [N7]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eI approach hesitancy, but with all the calm in the world, I mean, without worrying about having to give explanations, and now I do it with total naturalness, thinking that I\u0026rsquo;m doing it well. [N4]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAbove all, it\u0026rsquo;s the confidence it gives you, more confidence when, above all, the change might be the most important one: not having to think and assume that they will be vaccinated. [P3]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eClearly, the emotional aspect\u0026mdash;how we feel about this communicative work\u0026mdash;well, in a course, you gave us skills, and I suppose that over time, as we put them into practice, we will feel more confident with the changes you\u0026rsquo;ve proposed. I think it\u0026rsquo;s still very recent, but I\u0026rsquo;m sure it\u0026rsquo;s helpful. [N8]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased empathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLosing the fear of the situation, being able to empathize more with those people who have doubts, saying, 'Well, I mean, they have doubts, let\u0026rsquo;s see, they may be founded or not, but it\u0026rsquo;s legitimate for them to have them,' and being able to approach it from a more empathetic point of view. [P2]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eI think it has helped me relate to them better. Because initially, they are vaccine hesitant and I am hesitant towards anti-vaxxers, right? (...) In this aspect, it has helped me, because before I felt like I took it very personally, right? (...) It helps to normalize it, knowing that it\u0026rsquo;s a real problem, that this type of patient exists, and to be able to engage with them. [P7]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheoretical learnings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRefreshing knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eIt refreshes everything about the safety and efficacy of vaccines. Of course, it\u0026rsquo;s always good to refresh it because sometimes, as a colleague said, we go into vaccination almost automatically, and we have it so clear and so internalized that many times it\u0026rsquo;s good to refresh what vaccines do. [N10]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes, I didn\u0026rsquo;t remember learning about the composition of vaccines in university, except for the egg and the more basic things... No, I wasn\u0026rsquo;t aware of the composition of vaccines. [P10]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganisational changes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReviewing patient's vaccination history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWe've always done it, reviewing vaccination cards one by one. [P7]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient recall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eI think we were already doing this before [referring to actively seeking patients with missed vaccines], and we\u0026rsquo;ve continued doing it. The course helps with that. [P3]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpportunistic vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWhat we've done the most is a lot, a lot, a lot of opportunistic vaccination, especially with the flu vaccine. That\u0026rsquo;s what has worked the most. [N1]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAfter this course, we haven\u0026rsquo;t made an organizational change, but well, we already do a lot, meaning we go on catching patients who come (...) not to get vaccinated, but for other reasons. [P4]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity outreach talks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eRegarding what you said about giving talks, (...) we also give some talks at the nearby daycare centre. [P10]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFostering a culture of vaccination within the centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWhat has changed a little with the team is that now, maybe more often, we meet, discuss incidents with some families, or talk a little more about vaccines. [N11]\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eI think what's pending, and I find it good, is involving the organization, making changes at an organizational level. To look at how we\u0026rsquo;re all doing, different professionals, even adults and paediatrics, (...) paediatrics obviously, and propose organizational changes within the team. [P9]\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eLegend: The flow and distribution of responses between T0 and T1 are visualized, with colours representing participant responses at T1. T0 responses are shown for all study participants (N\u0026thinsp;=\u0026thinsp;141), while T1 responses include only those who completed the follow-up (n\u0026thinsp;=\u0026thinsp;135). For outcomes marked with an *, responses are provided only for participants who had encountered a vaccine-hesitant family in the prior four months at T1 (control arm: n\u0026thinsp;=\u0026thinsp;58 at T0, 55 at T1; intervention arm: n\u0026thinsp;=\u0026thinsp;68 at T0, 66 at T1). Abbreviations: DK/DA: don\u0026rsquo;t know/don\u0026rsquo;t answer; NA: not applicable; VH: vaccine hesitant.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eLegend: Figure A. The flow and distribution of responses from T0 to T1 are visualized, with colours denoting participant responses at T1. T0 responses are shown for all study participants (N\u0026thinsp;=\u0026thinsp;141), while T1 responses include only those who completed the follow-up (n\u0026thinsp;=\u0026thinsp;135). Abbreviations: NAND: neither agree nor disagree. Figure B: Each dot represents an individual participant's self-efficacy score. The boxplots illustrate the distribution of scores within each study arm\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSecondary outcomes related to vaccine knowledge and beliefs are reported in Supplementary Material Table S3, whereas organizational changes are reported in Supplementary Material Table S4. Although significant improvements were observed in vaccine knowledge, qualitative findings show that PHCWs felt that they already had sufficient theoretical knowledge, especially paediatricians. Nonetheless, they acknowledged the value of reviewing challenging topics, such as vaccine composition and side effects. Regarding organizational changes, we did not find a significant overall increase in the use of organizational practices to promote vaccination. Qualitative results show that many participants had already implemented some of these practices prior to the program, including reviewing vaccination history, patient recalls, and opportunistic vaccination.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eProcess evaluation\u003c/h2\u003e \u003cp\u003eAmong participants in the intervention arm, 75 (97.4%) attended the in-person session, 74 (96.1%) took the final multi-choice test, and 69 (89.6%) filled the satisfaction survey. Mean overall satisfaction was 8.7 out of 10 (SD: 0.9, range 7 to 10), all respondents (100%) would recommend the program to colleagues, and 97% found CONFIVAC quite or very applicable to their daily practice. Secondary satisfaction outcomes are summarised in Supplementary Material Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e. In focus group discussions (Supplementary Material Table S5), participants emphasized the course usefulness and positively evaluated its format, materials, and contents, particularly the module on communications strategies. The asynchronous online component was appreciated for enabling flexible completion, while the in-person component was valued for the opportunity to practice theory through role-playing exercises and to share vaccine-related experiences with colleagues.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe implemented and evaluated CONFIVAC, a training program designed to improve knowledge, beliefs, attitudes, self-efficacy, and vaccine-promoting behaviours among PHCWs. Four months after baseline, PHCWs in the intervention arm were significantly more likely to systematically use a presumptive communication and anticipate upcoming vaccines, but not of explicitly recommending vaccination. They also reported feeling more prepared and a higher self-efficacy in managing VH. Qualitative findings suggest that PHCWs have adopted communication tools to recommend vaccination that they perceive as effective and confidently engage in vaccine discussions with hesitant families. The program also reduced PHCW\u0026rsquo;s anxiety while increasing their empathy during these interactions. The process evaluation revealed high satisfaction with the program, which participants found both useful and applicable to their daily practice.\u003c/p\u003e \u003cp\u003eKey effectiveness outcomes were the adoption of vaccine-promotion behaviours associated with increased vaccine acceptance, such as the use of a presumptive approach \u0026mdash;presenting vaccines as a given rather than a choice\u0026mdash; when initiating vaccine conversations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. CONFIVAC reinforced the systematic use of this approach while improving PHCWs\u0026rsquo; confidence and reducing feelings of guilt when using it. In addition, it also improved the behaviour of anticipating future vaccinations. This primes individuals by reinforcing vaccination as a default behaviour and a societal norm, keeping it present in their minds, and potentially predisposing them to seek information, thereby facilitating open communication channels between families and PHCWs [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A strong provider recommendation is another well-established effective strategy for increasing vaccination [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While the difference in systematically making an explicit vaccine recommendation in cases of VH was not statistically significant between study arms, this might be due to the small sample size and the fact that PHCWs may view recommending vaccines as a \"default\" behaviour, making explicit recommendations less salient. Qualitative findings support this idea, as PHCWs did not specifically mention explicit recommendations during discussions, despite reporting successful examples of their use of tools introduced by CONFIVAC to strengthen vaccine recommendations. Interestingly, the proportion of participants that \u0026ldquo;very often\u0026rdquo; make explicit vaccine recommendations increased 13% in the intervention arm (compared to 3% in the control arm), suggesting that indeed the intervention had some effect. Finally, CONFIVAC significantly increased PHCWs' perception of having sufficient training to address VH, effectively meeting a training gap previously identified worldwide [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This is particularly important, as prior studies have underscored the need for targeted interventions to equip healthcare providers with the necessary skills and knowledge to effectively manage VH [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence supporting educational interventions to address VH remains limited, particularly outside the United States [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A 2018 Cochrane systematic review found low- to moderate-certainty evidence that education-based interventions for caregivers increase childhood vaccination rates, with even less certainty regarding their effectiveness for VH families [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Similarly, interventions that focus on increasing theoretical vaccine knowledge among PHCWs seem to have minimal impact on vaccination uptake, despite increasing PHCWs\u0026rsquo; self-confidence [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In contrast, CONFIVAC emphasizes \u003cem\u003ehow\u003c/em\u003e to deliver vaccine-related messages, rather than just focusing on \u003cem\u003ewhat\u003c/em\u003e to communicate. This approach is consistent with the findings from two systematic reviews on effective interventions to address VH and increase vaccine uptake [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], which underscore the importance of communication training. However, previous interventions varied in scope in scope and used different evaluation methods, often lacking a control group, making direct comparisons with our results challenging [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Commonly used communication strategies in these interventions were the use of presumptive communication and motivational interviewing (MI), either alone or in combination [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], both of which have shown to increase vaccine uptake [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. CONFIVAC follows this trend, while also extending its scope by offering a wider range of additional communication tools, such as making strong vaccine recommendations, tailoring vaccine-related messages to caregivers needs, sharing personal stories, or debunking myths when needed while avoiding a backfire effect [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to educational interventions, organizational strategies have also proven effective in increasing vaccine uptake [12, 26, 36], and may also reduce the individual burden of vaccine-related tasks by streamlining workflows and promoting shared responsibilities [37]. Thus CONFIVAC also includes a module on organizational practices both within consultations (e.g., reviewing immunization records, anticipating vaccines, opportunistic vaccination) and across PHC teams (e.g., reminders, recalls, and school vaccination efforts) to foster a vaccination culture. However, many of these strategies were already partially established prior to CONFIVAC. For example, in Catalonia PHC teams use a shared electronic health records system with an integrated vaccine register that facilitates reviewing a patient\u0026rsquo;s immunization status, flags missed vaccines and proposes future ones. In addition, vaccine uptake objectives among PHCWs are linked to economic incentives, standing orders allow nurses to administer routine vaccines without individual physician approval, vaccines for school-age children are delivered at schools, and text messaging campaigns are occasionally used. Therefore, CONFIVAC\u0026rsquo;s primary focus was to equip PHCWs with the skills to reinforce and consistently utilize these existing tools, while introducing adaptable practices for specific contexts, rather than pursuing a broad organizational redesign. Thus, the absence of statistically significant changes in organizational practices probably reflects their pre-existing implementation, as corroborated by focus group discussions. Additionally, the post-intervention measurement period may have been too short to detect meaningful changes. Finally, we also acknowledge that training PHCWs alone may be insufficient for broader organizational changes, which often require additional resources and structural support.\u003c/p\u003e \u003cp\u003eAnother key finding of our study is the increase in self-efficacy to handle VH, consistent with previous studies on vaccine-related educational interventions for healthcare workers [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Given that self-efficacy has been shown to be associated with vaccine recommendations and acceptance [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], this improvement is significant. Participants also reported feeling less anxious and experiencing a greater sense of accomplishment. This is particularly relevant given that PHCWs often feel emotional distress when dealing with VH situations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A recent scoping review highlighted that many existing interventions fail to address the emotional burden associated with these encounters, leaving healthcare workers unprepared to manage their own feelings effectively [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. To bridge this gap, our intervention included a dedicated module on emotional management, equipping PHCWs with tools for self-monitoring and regulation during challenging consultations. These findings highlight the importance of addressing both vaccination-related and PHCW\u0026rsquo;s emotional well-being [16, 38].\u003c/p\u003e \u003cp\u003eThe major strength of this study lies in its robust evaluation, which employed a mixed-methods design combining a cluster-randomized clinical trial with a qualitative study. Additionally, CONFIVAC was developed using a grounded methodology (Intervention Mapping)[39] and included inputs from paediatric practitioners, ensuring its alignment with real-world healthcare needs. Relevance and timeliness are further demonstrated by the high prevalence of VH in our setting, with 90% of participants reporting recent encounters with VH families. Addressing such a widespread issue, alongside the involvement of paediatric practitioners, likely contributed to CONFIVAC\u0026rsquo;s successful implementation, which was marked by high levels of satisfaction, perceived usefulness, and strong adoption rates. These outcomes highlight the program\u0026rsquo;s practical value and reinforce its strength as a context-responsive intervention. Moreover, CONFIVAC fills a critical gap in the literature, as few interventions targeting VH have been conducted and evaluated with control groups and using a mixed methods design in European countries. Another key strength of CONFIVAC is its comprehensive scope. The program covers a broad range of training content, including theoretical knowledge, communication skills, and organizational strategies. It is also inclusive in its approach, targeting both nurses and physicians, and focuses on systematic vaccines rather than a single vaccine. The program\u0026rsquo;s hybrid format is another significant advantage. The online training component enhances accessibility and sustainability [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], while the two-hour in-person session\u0026mdash;featuring activities such as role-playing\u0026mdash;are likely to increase effectiveness, as supported by previous evidence [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, this study has also limitations. First, the sample size was small, and the follow-up period was limited to four months after the baseline, and in some cases, just one month after the end of the intervention. This short timeframe may hinder the possibility to observe certain changes or to fully assess the program's long-term effects. Second, social desirability bias (i.e., participants overreporting positive outcomes) could also affect the validity of the results. Third, outcomes were measured among providers rather than caregivers, meaning that changes in providers' practices were not assessed from the caregivers' perspective, and the intervention\u0026rsquo;s impact was not assessed at the family level. Additionally, no data were collected on vaccine coverage, so the direct impact of the program on vaccination uptake remains unknown. While this was not an objective of the current study, we plan to explore the impact of CONFIVAC on vaccine coverage in the future. However, previous evidence suggests that communication-focused interventions can improve vaccine uptake and reduce vaccine hesitancy among caregivers [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCONFIVAC, a comprehensive training program for PHCWs encompassing vaccine knowledge, communication skills, and organizational tools, was associated with short-term improvements in vaccine-promoting behaviours, self-efficacy in addressing VH, and vaccine-related knowledge. Additionally, it had a positive impact on PHCWs' emotional well-being, an area underexplored in the literature. This study underscores the value of targeted, accessible, and behavioural models-based training programs in enhancing healthcare workers' skills and confidence in promoting vaccines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVH: vaccine hesitancy; PHCW: paediatric healthcare worker; PPH: primary paediatric healthcare; SD: standard deviation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Drug Research Ethics Committee Parc de Salut MAR (CEIm-PSMAR)( 2021/9729/I) and by IDIAP Jordi Gol Clinical Research Ethics Committee (CEIm)(22/194-P).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot aplicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by \u003cem\u003eFondo de Investigaciones Sanitarias\u003c/em\u003e from Instituto de Salud Carlos III (ISCIII), Ministry of Science and Innovation, Spain, through the Health Research Projects (AES 2021) program and cofunded by the European Union, grant no. PI21/01710.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eED, SV, VP, AA, EH, and ER conceptualized the study and developed the methodology, with valuable contributions from XB. ED, SV, EH, ER, and ARM oversaw project administration. ED secured funding and supervised the work. ER, EH, SV, AA, and VP analyzed and interpreted the data. ER drafted the initial manuscript with insightful contributions from AA, SV, VP, EH, and ED. All authors contributed to manuscript review and editing and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the feedback provided by Anna Borja, Anna Gatell, Anna Ramon, Àurea Arce, Blanca Macias, Claudia Solito, Ester Mateus, Maria Arranz, Maria Esther Isern, María García, Maria Pueyo, Mireia Biosca, Mireia Garcia, Montserrat Guarido, Montserrat Melo, Noelia González, Pepe Serrano, Ramon Capdevila, Raquel Muñoz, Roger Benavent, Nieves Barragán, and Marina Prades who supported the development of the training program materials and questionnaires. We also thank Ricard Codina for his support with the online platform and Asunción Martínez for directing the video cases. We are also grateful to the volunteers who performed as actors and actresses in the video cases—Anna Pérez, Cristina Delgado, Étienne Pagès, Guillem Albornà, Itziar Falcón, Ivan Martí, Maira Carolina Guzmán, Manon Pueller, Sandra Cuspinera, and Sonia Gil. Additionally, we acknowledge Beatriz Román for lending her voice to the materials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMembers of the CONFIVAC Research Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarta Cabanas \u003csup\u003eg\u003c/sup\u003e, Carmen Gallego \u003csup\u003eh\u003c/sup\u003e, Usue Elizondo-Alzola \u003csup\u003ei\u003c/sup\u003e, David Palma \u003csup\u003ec,j\u0026nbsp;\u003c/sup\u003e, Camila A Picchio \u003csup\u003ek\u003c/sup\u003e, Gemma Ric\u0026oacute;s,\u003csup\u003el,m\u003c/sup\u003e Paula Santi\u0026agrave; \u003csup\u003ea,h\u003c/sup\u003e, Josep Vidal-Alaball \u003csup\u003ed,n,o\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Ag\u0026egrave;ncia de Salut P\u0026uacute;blica de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u0026nbsp;\u003c/sup\u003eCIBER Epidemiolog\u0026iacute;a y Salud P\u0026uacute;blica (CIBERESP),\u0026nbsp;Instituto de Salud Carlos III, C/Monforte de Lemos 3-5. Pabell\u0026oacute;n 11, 28029, Madrid, Spain\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ed\u003c/sup\u003e Unitat de Recerca i Innovaci\u0026oacute;, Ger\u0026egrave;ncia d\u0026apos;Atenci\u0026oacute; Prim\u0026agrave;ria i a la Comunitat de la\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eg\u003c/sup\u003e Directora de Sectors Sanitaris, AIS Barcelona Litoral Mar, Consorci Sanitari de Barcelona, Spain\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eh\u003c/sup\u003e Unitat de Metodologia, Qualitat i Avaluaci\u0026oacute; Assistencial, Ger\u0026egrave;ncia d\u0026rsquo;Atenci\u0026oacute; Prim\u0026agrave;ria i a la Comunitat Delta, Institut Catal\u0026agrave; de la Salut, Barcelona, Spain\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ei \u0026nbsp;\u003c/sup\u003eFarmacia de Atenci\u0026oacute;n Primaria, Osakidetza-Sevicio Vasco de Salud (OSI Debagoiena), Avd. Nafarroa, 16, 20500, Gipuzkoa, Spain\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ej\u003c/sup\u003e Department of International Health, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ek\u0026nbsp;\u003c/sup\u003eBarcelona Institute for Global Health (ISGlobal), Hospital Cl\u0026iacute;nic, University of Barcelona, Barcelona, Spain\u003c/p\u003e\n\u003cp\u003e\u003csup\u003el\u0026nbsp;\u003c/sup\u003eInstitut Catal\u0026agrave; de la Salut, Gran Via de les Corts Catalanes 587, 08007, Barcelona, Spain\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003em\u003c/sup\u003e Departament de Salut, Travessera de les Corts, 131, 159, Les Corts, 08028, Barcelona, Spain\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003en\u003c/sup\u003e Intelligence for Primary Care Research Group, Fundaci\u0026oacute; Institut Universitari per a la Recerca a l\u0026apos;Atenci\u0026oacute; Prim\u0026agrave;ria de Salut Jordi Gol i Gurina, Manresa, Spain\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eo\u003c/sup\u003e Department of Medicine, Faculty of Medicine, University of Vic-Central, University of Catalonia, Vic, Spain\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. Ten threats to global health in 2019. 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019. Accessed 3 Oct 2024.\u003c/li\u003e\n \u003cli\u003eMacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33:4161\u0026ndash;4.\u003c/li\u003e\n \u003cli\u003eBraun C, O\u0026rsquo;Leary ST. Recent advances in addressing vaccine hesitancy. Curr Opin Pediatr. 2020;32:601\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eWilson SL, Wiysonge C. Social media and vaccine hesitancy. BMJ Glob Health. 2020;5:e004206.\u003c/li\u003e\n \u003cli\u003eMascherini M, Nivakoski S. Social media use and vaccine hesitancy in the European Union. Vaccine. 2022;40:2215\u0026ndash;25.\u003c/li\u003e\n \u003cli\u003eDe Waele A, Hendrickx G, Valckx S, Dom\u0026iacute;nguez \u0026Agrave;, Toledo D, Castilla J, et al. The Vaccine Training Barometer: Assessing healthcare providers\u0026rsquo; confidence to answer vaccine-related questions and their training needs. Vaccine. 2024;42:2421\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eLarson HJ, Gakidou E, Murray CJL. The Vaccine-Hesitant Moment. New England Journal of Medicine. 2022;387:58\u0026ndash;65.\u003c/li\u003e\n \u003cli\u003eFigueiredo A De, Eagan RL, Hendrickx G, Karafillakis E, Van Damme P, Larson HJ. State of Vaccine Confidence in the European Union 2022. 2022. https://doi.org/10.2875/188426.\u003c/li\u003e\n \u003cli\u003eDepartament de Salut. ORDRE SLT/167/2023, de 21 de juny, per la qual s\u0026rsquo;actualitza el calendari de vacunacions sistem\u0026agrave;tiques. 2023.\u003c/li\u003e\n \u003cli\u003eBenin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative Analysis of Mothers\u0026rsquo; Decision-Making About Vaccines for Infants: The Importance of Trust. Pediatrics. 2006;117:1532\u0026ndash;41.\u003c/li\u003e\n \u003cli\u003eBrewer NT. What Works to Increase Vaccination Uptake. Acad Pediatr. 2021;21:S9\u0026ndash;16.\u003c/li\u003e\n \u003cli\u003eOlson O, Berry C, Kumar N. Addressing Parental Vaccine Hesitancy towards Childhood Vaccines in the United States: A Systematic Literature Review of Communication Interventions and Strategies. Vaccines (Basel). 2020;8:590.\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Leary ST, Opel DJ, Cataldi JR, Hackell JM, COMMITTEE ON INFECTIOUS DISEASES, COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, et al. Strategies for Improving Vaccine Communication and Uptake. Pediatrics. 2024;153.\u003c/li\u003e\n \u003cli\u003eDempsey AF, O\u0026rsquo;Leary ST. Human Papillomavirus Vaccination: Narrative Review of Studies on How Providers\u0026rsquo; Vaccine Communication Affects Attitudes and Uptake. Acad Pediatr. 2018;18:S23\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eConnors JT, Slotwinski KL, Hodges EA. Provider-parent Communication When Discussing Vaccines: A Systematic Review. J Pediatr Nurs. 2017;33:10\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eLimaye RJ, Opel DJ, Dempsey A, Ellingson M, Spina C, Omer SB, et al. Communicating With Vaccine-Hesitant Parents: A Narrative Review. Acad Pediatr. 2021;21:S24\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003ePahud B, Elizabeth Williams S, Lee BR, Lewis KO, Middleton DB, Clark S, et al. A randomized controlled trial of an online immunization curriculum. Vaccine. 2020;38:7299\u0026ndash;307.\u003c/li\u003e\n \u003cli\u003eHolford D, Anderson EC, Biswas A, Garrison A, Fisher H, Brosset E, et al. Healthcare professionals\u0026rsquo; perceptions of challenges in vaccine communication and training needs: a qualitative study. BMC primary care. 2024;25.\u003c/li\u003e\n \u003cli\u003ePicchio CA, Carrasco MG, Sagu\u0026eacute;-Vilavella M, Rius C. Knowledge, attitudes and beliefs about vaccination in primary healthcare workers involved in the administration of systematic childhood vaccines, Barcelona, 2016/17. Eurosurveillance. 2019;24:1.\u003c/li\u003e\n \u003cli\u003eLip A, Pateman M, Fullerton MM, Chen HM, Bailey L, Houle S, et al. Vaccine hesitancy educational tools for healthcare providers and trainees: A scoping review. Vaccine. 2023;41:23\u0026ndash;35.\u003c/li\u003e\n \u003cli\u003eHenderson E, Valmayor S, Porth\u0026eacute; V, Asensio A, Bruna X, Elizondo-Alzola U, et al. Confivac, an Intervention to Enhance Paediatric Nurses\u0026rsquo; and Paediatricians\u0026rsquo; Skills to Promote Vaccination and Vaccine Confidence: A Mixed Methods Study Protocol. 2025.\u003c/li\u003e\n \u003cli\u003eSanitaris Pediatria De Barcelona P DE. Retic\u0026egrave;ncia vacunal en els professionals sanitaris de pediatria de Barcelona. TDX (Tesis Doctorals en Xarxa). 2023.\u003c/li\u003e\n \u003cli\u003eBarton SM, Calhoun AW, Bohnert CA, Multerer SM, Statler VA, Bryant KA, et al. Standardized Vaccine-Hesitant Patients in the Assessment of the Effectiveness of Vaccine Communication Training. J Pediatr. 2022;241:203-211.e1.\u003c/li\u003e\n \u003cli\u003eGagneur A, Gosselin V, Bergeron J, Farrands A, Baron G. Development of motivational interviewing skills in immunization (MISI): a questionnaire to assess MI learning, knowledge and skills for vaccination promotion. Hum Vaccin Immunother. 2019;15:2446\u0026ndash;52.\u003c/li\u003e\n \u003cli\u003eSharp CA. Qualitative Research and Evaluation Methods (3rd ed.). https://doi.org/101177/1035719X0300300213. 2003;3:60\u0026ndash;1.\u003c/li\u003e\n \u003cli\u003eBrewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing Vaccination: Putting Psychological Science Into Action. Psychological Science in the Public Interest. 2017;18:149\u0026ndash;207.\u003c/li\u003e\n \u003cli\u003eLin C, Mullen J, Smith D, Kotarba M, Kaplan SJ, Tu P. Healthcare Providers\u0026rsquo; Vaccine Perceptions, Hesitancy, and Recommendation to Patients: A Systematic Review. Vaccines (Basel). 2021;9:713.\u003c/li\u003e\n \u003cli\u003eGagneur A, Gutnick D, Berthiaume P, Diana A, Rollnick S, Saha P. From vaccine hesitancy to vaccine motivation: A motivational interviewing based approach to vaccine counselling. Hum Vaccin Immunother. 2024;20.\u003c/li\u003e\n \u003cli\u003eLo Moro G, Ferrara M, Langiano E, Accortanzo D, Cappelletti T, De Angelis A, et al. Countering vaccine hesitancy: a systematic review of interventions to strengthen healthcare professionals\u0026rsquo; action. Eur J Public Health. 2023;33:905\u0026ndash;15.\u003c/li\u003e\n \u003cli\u003eJarrett C, Wilson R, O\u0026rsquo;Leary M, Eckersberger E, Larson HJ, Eskola J, et al. Strategies for addressing vaccine hesitancy - A systematic review. Vaccine. 2015;33:4180\u0026ndash;90.\u003c/li\u003e\n \u003cli\u003eKaufman J, Ryan R, Walsh L, Horey D, Leask J, Robinson P, et al. Face-to-face interventions for informing or educating parents about early childhood vaccination. Cochrane Database of Systematic Reviews. 2018;2018.\u003c/li\u003e\n \u003cli\u003eCole JW, M.H. Chen A, McGuire K, Berman S, Gardner J, Teegala Y. Motivational interviewing and vaccine acceptance in children: The MOTIVE study. Vaccine. 2022;40:1846\u0026ndash;54.\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Leary ST, Spina CI, Spielvogle H, Robinson JD, Garrett K, Perreira C, et al. Development of PIVOT with MI: A motivational Interviewing-Based vaccine communication training for pediatric clinicians. Vaccine. 2023;41:1760\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eOpel DJ, Robinson JD, Spielvogle H, Spina C, Garrett K, Dempsey AF, et al. \u0026lsquo;Presumptively Initiating Vaccines and Optimizing Talk with Motivational Interviewing\u0026rsquo; (PIVOT with MI) trial: a protocol for a cluster randomised controlled trial of a clinician vaccine communication intervention. BMJ Open. 2020;10:e039299.\u003c/li\u003e\n \u003cli\u003eTuckerman J, Kaufman J, Danchin M. Effective Approaches to Combat Vaccine Hesitancy. Pediatric Infectious Disease Journal. 2022;41:e243\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eSummary CPSTF Findings Table for Increasing Vaccination | The Community Guide. https://www.thecommunityguide.org/pages/task-force-findings-increasing-vaccination.html. Accessed 24 Dec 2024.\u003c/li\u003e\n \u003cli\u003eDeChant PF, Acs A, Rhee KB, Boulanger TS, Snowdon JL, Tutty MA, et al. Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review. Mayo Clin Proc Innov Qual Outcomes. 2019;3:384\u0026ndash;408.\u003c/li\u003e\n \u003cli\u003eBoissy A, Windover AK, Bokar D, Karafa M, Neuendorf K, Frankel RM, et al. Communication Skills Training for Physicians Improves Patient Satisfaction. J Gen Intern Med. 2016;31:755.\u003c/li\u003e\n \u003cli\u003eBartholomew LK, Parcel GS, Kok G, Gottlieb NH, \u0026amp; Schaalma H, Markham C, et al. Planning health promotion programs: An intervention mapping approach. 2nd edition. Jossey-Bass/Wiley; 2006.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Vaccination hesitancy, Vaccination, Paediatrics, Education, Professional, Communication, Cluster Randomised Clinical Trial","lastPublishedDoi":"10.21203/rs.3.rs-6021302/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6021302/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVaccine hesitancy (VH) poses a significant challenge to achieving optimal vaccination coverages worldwide. Paediatric healthcare workers (PHCWs) are fundamental in promoting vaccination but often lack adequate training to address VH. We designed CONFIVAC, an evidence-based training program developed using intervention mapping to enhance PHCWs' knowledge, self-efficacy, and skills in managing VH and fostering a culture of immunization in primary care. This study aimed to evaluate its effectiveness.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a mixed methods study including a cluster-randomized controlled trial with142 PHCWs in Barcelona and Central Catalonia, Spain from October 2023 to February 2024 and a qualitative study using a thematic analysis. Paediatric teams were randomized into intervention (CONFIVAC) and control (standard care) arms. CONFIVAC included 12 hours of online and in-person training on vaccine knowledge, communication strategies, and organizational tools. Outcomes were assessed through self-administered questionnaires at baseline (T0) and four months later (T1). Key outcomes included vaccine-promoting behaviours (presumptive communication, anticipation of upcoming vaccines, and explicit vaccine recommendations) and self-perception of adequate training to handle VH. We performed logistic regression models to estimate odds ratios (OR) with 95% confidence intervals using an intention-to-treat approach. Focus groups provided qualitative insights.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAt T1, PHCWs in the intervention arm were more likely to use presumptive communication (aOR: 4.05 [2.30;7.15]) and anticipate upcoming vaccines (aOR: 2.64 [1.50;4.65]) than controls. Explicitly recommending vaccination when encountering cases of VH did not reach statistical significance (aOR: 1.75 [0.89;3.44]). Self-perception of adequate training was higher in the intervention arm (aOR: 3.85 [2.10;7.03]). Satisfaction with the training was high, and focus group participants reported improved communication strategies, more empathy towards VH families, and increased confidence in managing VH situations.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eCONFIVAC enhanced PHCWs' vaccine-promoting behaviours and self-efficacy, demonstrating the value of accessible, evidence-based training programs to support vaccination efforts in routine practice.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eClinicalTrials NCT06489236\u003c/p\u003e","manuscriptTitle":"Effectiveness of CONFIVAC, an intervention to enhance Paediatric Nurses and Paediatricians skills to promote vaccination: a mixed-methods cluster randomised clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-27 06:48:52","doi":"10.21203/rs.3.rs-6021302/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"037b8f34-b0b4-40b7-b50b-82369bbac602","owner":[],"postedDate":"February 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-27T06:48:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-27 06:48:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6021302","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6021302","identity":"rs-6021302","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}