Vaccine hesitancy: Opinion of people responsible for the care of infants in Barcelona

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array:3 [ "entidad" => "Agència de Salut Pública de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "af0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red Epidemiología y Salud Pública (CIBERESP), Madrid, Spain" "etiqueta" => "b" "identificador" => "af0010" ] 2 => array:3 [ "entidad" => "Institut d'Investigació Biomèdica (IBB Sant Pau), Barcelona, Spain" "etiqueta" => "c" "identificador" => "af0015" ] 3 => array:3 [ "entidad" => "Departamento de Ciencias Experimentales y de la Salud, Universitat Pompeu Fabra, Barcelona, Spain" "etiqueta" => "d" "identificador" => "af0020" ] 4 => array:3 [ "entidad" => "Universitat Pompeu Fabra, Barcelona, Spain" "etiqueta" => "e" "identificador" => "af0025" ] 5 => array:3 [ "entidad" => "Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "f" "identificador" => "af0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cr0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reticencia vacunal: opinión de las personas responsables de los cuidados de infantes en Barcelona" ] ] "textoCompleto" => "IntroductionVaccination prevents between 2 and 3 million deaths per year worldwide and is one of the most cost-effective preventive strategies.<a class="elsevierStyleCrossRef" href="#bb0005">1</a> However, the World Health Organisation (WHO) lists vaccine reluctance as one of the major threats to global health.<a class="elsevierStyleCrossRef" href="#bb0010">2</a> Vaccine reluctance is defined as refusal, hesitancy or delay in vaccination, a complex and context-dependent phenomenon that can compromise population health. It ranges from hesitant acceptance of all vaccines to complete refusal to late acceptance and partial refusal.<a class="elsevierStyleCrossRef" href="#bb0015">3</a>The WHO Expert Group on Immunisation SAGE)<a class="elsevierStyleCrossRef" href="#bb0015">3</a> classifies the determinants of reluctance into: 1) contextual factors, including the media and its media outreach and socio-economic and cultural elements, 2) individual and group factors, encompassing beliefs about vaccines, risk perception and social norm, among others; and 3) vaccination-specific factors, including vaccine characteristics and schedule of administration.<a class="elsevierStyleCrossRef" href="#bb0020">4</a>In order to formulate effective interventions against reluctance, it is necessary to understand the context, determinants and challenges in each territory.<a class="elsevierStyleCrossRef" href="#bb0025">5</a> In Spain, although vaccination is not compulsory, coverage reaches 97% for most of the vaccines on the routine vaccination schedule.<a class="elsevierStyleCrossRef" href="#bb0030">6</a> The few surveys available<a class="elsevierStyleCrossRef" href="#bb0035">7</a>,<a class="elsevierStyleCrossRef" href="#bb0040">8</a> estimate that 10%–15% of the population is reluctant to be vaccinated, although in the 2016 Barcelona Health Survey (BHS), only 1.5% of minors were not vaccinated for non-medical reasons.<a class="elsevierStyleCrossRef" href="#bb0045">9</a>Although reluctance is not a current threat to public health in Spain, there are doubts about vaccination in some sectors of the population, including some health professionals, and the growing trend of the media effect of the anti-vaccine movement is a concern for future collective health.<a class="elsevierStyleCrossRef" href="#bb0050">10</a>Given that most of the vaccines on the routine vaccination schedule (free of charge in our context) are administered at paediatric age and that the decision to vaccinate falls to the people responsible for the children (mainly mothers, fathers or legal guardians), it is of interest to know their opinions in depth in order to guide interventions to address this phenomenon. Reluctance has been studied in several contexts,<a class="elsevierStyleCrossRefs" href="#bb0055">11–13</a> but in our setting we have little information on the opinions and knowledge of those responsible for infants. In addition, the COVID-19 pandemic has highlighted both the importance of vaccination in the control of communicable diseases and the challenge of vaccine reluctance.This study therefore aims to: a) describe the views on vaccination of caregivers of infants aged 0–7 years with different profiles of vaccine reluctance in Barcelona; b) describe the elements contributing to vaccine reluctance; and c) explore suggestions and proposals to reduce reluctant practices.Material and methodsDesignA qualitative exploratory-descriptive phenomenological study.Scope and study populationthe fieldwork was conducted in Barcelona between January and March 2021. The study population were the people responsible for the care of one or more infants aged 0 to 7 years, resident in the city and who expressed some type of vaccine reluctance. Different profiles of reluctance were included: acceptance with hesitation, delay and refusal of some or all vaccines. Those who expressed extreme refusal were excluded because they tend to be unresponsive to dialogue.<a class="elsevierStyleCrossRef" href="#bb0070">14</a>SamplingTheoretical, maximum variation for gender, age and educational level. Segmentation criteria were based on the district of residence, selecting one high-income and one low-income district, to include possible aspects related to inequality. Recruitment was made through posters in public spaces and information on social networks, mainly WhatsApp. The main sampling strategy was snowballing. Given the difficulty in accessing the population residing in these districts, because they represent a low percentage of the population and because of the pandemic, district was eliminated as a segmentation criterion in the final design. The final sample included 13 participants residing in Barcelona. The majority were first-time mothers, aged 30–40 years, with secondary or university education, children aged 2 months to 7 years and with the intention to vaccinate, although with doubts, delay or partial refusal (<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>). In the description of the results, we will use the generic female to refer to all the people interviewed.<elsevierMultimedia ident="t0005"></elsevierMultimedia>Data collectionSemi-structured individual interviews (average length 45 min) were conducted with a script that explored the factors defined by SAGE.<a class="elsevierStyleCrossRef" href="#bb0015">3</a> Due to the pandemic, participants were offered a variety of interview formats: face-to-face, online or telephone. Most were conducted non-face-to-face.Data analysis and qualityThe interviews were audio-recorded and then transcribed. Thematic analysis was carried out using Atlas.ti software. The categories of analysis were generated from the script and from the analysis of the information, through constant comparison of the data. To ensure rigour and quality of information, data were triangulated between researchers (IR, AA, VP) and with the literature.Ethical aspectsparticipants received written information about the study and gave informed consent. Voluntary participation, anonymity and data protection were ensured. An identification code including number, gender and level of education was assigned. This study has the approval of the Ethics Committee of ParcSalut MAR (2021/10136).ResultsThe description of the results is inspired by the SAGE<a class="elsevierStyleCrossRef" href="#bb0015">3</a> framework: contextual, individual-group, and vaccination-specific factors. However, factors related to health services emerged strongly from the analysis, which, although considered vaccination-specific in the framework, led to the creation of a new category that was analysed separately. The results refer to public health services and are otherwise specified. Due to space limitations, most of the citations are collected in <a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>.<elsevierMultimedia ident="t0010"></elsevierMultimedia>Health services factorsTwo issues related to the interaction between health professionals and users emerge from the discourse: the treatment received and communication. With regard to treatment, mothers state that expressing their doubts or rejection of vaccines in the consultation room may condition the professional treatment received. Some mothers report uncomfortable, derogatory or aggressive experiences: “Let's see, but do you understand that you have to vaccinate, that you can't go around with your child unvaccinated”, MU-1. Several reported feeling pressured to vaccinate, sometimes through fear-mongering discourse, “Most of the times I have suggested an alternative, the response has been to scare me, like: ‘Be careful, don't leave the fold’”, MU-4. However, they also point out a certain variability in the professional treatment, referring to positive experiences associated with an understanding attitude, “The staff who attended us told us: “There is no problem, it is your criteria””, MU-1.With regard to communication, all the participants consider that the information received from the health services is scarce, “They gave me a DIN-A4 sheet of paper on one side, with 4 things on it with the first vaccination. That is not informing the patient”, MU-8. Moreover, it is not provided in advance and some mothers are caught unawares. When they ask for more information, the information they receive seems insufficient and/or complex. They point out that the lack of time in the consultation room and the rigidity of the technical discourse produce a feeling of standardisation that worsens professional-user communication.The little information they receive from the health services, added to the treatment that they sometimes consider to be lackadaisical, causes these mothers to delay or partially refuse vaccination while they seek the information they do not obtain from the services: “Since the information does not come to you, let's go and look for it”, MU-1. Sometimes they seek a second medical opinion, generally from the private sector, or they turn to non-biomedical professionals who become references and many of them advocate reticence.Specific vaccination factorsA lack of information about vaccines and their characteristics is identified in the mothers' discourse, which is evident in the lack of knowledge about the vaccines most recently incorporated into the schedule, the belief in supposedly harmful components present in vaccines (egg or mercury), or their supposed association with autism.This also seems to influence the mothers' perception of the vaccination schedule, which arouses distrust in 3 aspects: the start, the number of vaccines and their application. They report that the first vaccinations are given at a very early age, and this increases the fear of adverse effects, including mild ones such as fever. Many mothers believe that the immune system in the first months of life is fragile and not ready to receive vaccines: “It seems to me that it starts too early and that at 2 months they are super small” MU-5. In addition, they consider that too many vaccines are given in too short a time. They are concerned about combined vaccines, especially hexavalent vaccines, because they do not allow them to choose the antigens separately.The majority of mothers express the desire to apply a vaccination schedule adapted to their needs. They give as examples the situation of infants who will not attend nursery school before their first birthday or those who, particularly during the COVID-19 pandemic, have been at home in the care of relatives: “With the current context of confinement, the child is in a bubble”, MU-1).In this way, the lack of information contributes to the perception of a schedule that is far removed from their needs and contributes to mothers delaying or refusing certain vaccinations.Individual and group factorsFrom this discourse, some common individual components are identified among the participants. In general, respondents express their need to be well-informed in order to make decisions and value information about vaccines because it provides them with autonomy and empowerment. They also need enough time to decide, and demand less pressure and more sensitivity on the part of health staff to the emotional burden of deciding about their children's health. These mothers express difficulties in forming a clear opinion about vaccines and perceive vaccination as an uncertain issue that makes them hesitant. They state that this is also contributed to by what the media says and the polarised positions of consultation sources, mainly on the Internet.Other factors that emerge from the discourse relate to the perception of risk and the health paradigm. The risk–benefit comparison between vaccinating and not vaccinating emerges: “I think both options are a risk”, MU-2. In addition, some mothers believe that vaccine-preventable diseases are unlikely, eradicated or not very serious in our environment. On the other hand, while most report confidence in the biomedical paradigm on which health services are based, they criticise over-medicating and the lack of consideration of the specificities of each person in the health-disease processes. Some mothers turn to alternative paradigms (homoeopathy, etc.) as a complement and leave the mainstream system as a last resort.As a result, some mothers who feel that they do not have the information they need to make decisions end up delaying their infants' vaccination. Low risk perception of some diseases and adherence to alternative health paradigms contribute to mistrust of vaccination and reluctant practices.Contextual factors: COVID-19 pandemicBecause of the context in the study period, the effect of the COVID-19 pandemic and the media coverage of its vaccine development was explored. Most mothers felt that the development of COVID-19 vaccines had had little influence because it was a different issue and, in all cases, their reluctance preceded the pandemic.SuggestionsThe interviews collected suggestions from respondents generally addressed to public health services (<a class="elsevierStyleCrossRef" href="#t0015">Table 3</a>). Most of them urged for information provided by the services to be improved, so that they would provide more information about vaccination and more tailored to the needs of those responsible for children: “More information and less invasion”, MU-8.<elsevierMultimedia ident="t0015"></elsevierMultimedia>DiscussionThe reluctance among this study's participants consists mainly of doubts, delays in first vaccinations of the schedule and refusal of some vaccinations. The main factors associated with these practices are the lack of information provided by the health services, the communication and treatment received at the health centre and individual doubts regarding the vaccination schedule.The SAGE model was conceived with the aim of defining the main factors influencing vaccine reluctance at a global level, but in specific contexts specificity is lost. In our study, factors related to health services emerged so strongly that they led to the creation of a specific category for such information. This is consistent with the context in Spain, where National Health System (NHS) health teams are key in access to vaccination and are the main source of information that may influence vaccine reluctance.<a class="elsevierStyleCrossRefs" href="#bb0075">15–17</a> Other factors such as contextual factors, contrary to expectations, were hardly mentioned.The lack of information on vaccination provided by public health services, accentuated by poor communication with paediatric professionals, with little time for each consultation, makes it difficult to form a clear opinion on vaccines, generates doubts and hinders decision-making on the vaccination of children.<a class="elsevierStyleCrossRef" href="#bb0075">15</a> Although most mothers recognised the importance of vaccines, some of the unresolved concerns called into question their decision to vaccinate. Extensive and rigorous information now exists that could address these concerns; however, it does not appear to be effectively or convincingly communicated to some families.<a class="elsevierStyleCrossRef" href="#bb0090">18</a> Part of these results could be explained by the lack of capacity to answer doubts expressed by 29% of paediatricians.<a class="elsevierStyleCrossRef" href="#bb0095">19</a> On the other hand, the mistrust of health services generated by the treatment received in the consultation room is consistent with studies that highlight the importance of respectful treatment and good communication to address reluctance in the consultation room.<a class="elsevierStyleCrossRef" href="#bb0075">15</a>,<a class="elsevierStyleCrossRef" href="#bb0100">20</a>In contrast to another study conducted in Spain,<a class="elsevierStyleCrossRef" href="#bb0065">13</a> in our results the move away from medicalisation and the prioritisation of “natural processes” does not appear as a relevant factor for reluctance. Instead, the non-biomedical paradigm emerges as a solution to the manifest dissatisfaction of some mothers, which is consistent with a study that indicates that reluctant people are more likely to distrust conventional sources and their information.<a class="elsevierStyleCrossRef" href="#bb0080">16</a>The willingness of these mothers to take an active part in the health of their infants and to make informed decisions is consistent with the new role that users are assuming in their relationship with health services: the active patient.<a class="elsevierStyleCrossRef" href="#bb0105">21</a> This patient is characterised by seeking optimal quality of care that allows them to establish a link with professional teams based on deliberation and empowerment as a patient, so that they can take proper responsibility for their health. This patient profile is positively associated with the level of education, so that the higher the level of education, the greater the responsibility for one's own health care.The lack of information on vaccines could partly explain these mothers' perception of the vaccination schedule and their desire to adapt it to their needs. Previous studies point to an increase in parents using an alternative schedule in recent decades due to concerns about some routine vaccines.<a class="elsevierStyleCrossRef" href="#bb0090">18</a>,<a class="elsevierStyleCrossRef" href="#bb0110">22</a>,<a class="elsevierStyleCrossRef" href="#bb0115">23</a> Other studies also point out that vaccine-averse individuals are concerned about vaccine safety, while pro-vaccination individuals prioritise disease prevention.<a class="elsevierStyleCrossRefs" href="#bb0120">24–26</a>Contrary to expectations, the development of COVID-19 vaccines during the study period was hardly relevant. In the case of these mothers, reluctance preceded the pandemic and the rapid development of vaccines did not influence the decision to vaccinate. However, it should be remembered that the interviews were conducted before the start of the population vaccination campaign against COVID-19 and the episodes of pharmacovigilance on some vaccines that generated media alarm.<a class="elsevierStyleCrossRef" href="#bb0135">27</a> The impact of the pandemic on routine vaccination will need to be assessed at a later stage.LimitationsOne limitation of the study is the homogeneity of the sample: first time mothers, aged 30 to 40 years, with secondary or graduate education and with a certain intention to vaccinate. This sample does not allow conclusions to be drawn regarding other socio-demographic variables that influence reluctance to vaccinate, such as socio-economic level.<a class="elsevierStyleCrossRef" href="#bb0140">28</a> The low male participation denotes the persistence of gender roles in caregiving: mothers are primarily responsible for the health of their children; the results are consistent with a similar study in the Spanish population.<a class="elsevierStyleCrossRef" href="#bb0145">29</a> Another possible limitation derives from the format of the interviews. The telematic format may have conditioned communication and the links established between the interviewer and the interviewee. However, the interviews were conducted one year into the pandemic, when a large part of the population with this socio-demographic profile had become familiar with virtual communication.Conclusions and recommendationsThe reluctance identified among participants is mainly attributed to the lack of information provided by the health services, to the communication and treatment received at the consultation and to unresolved doubts regarding the vaccination schedule.This study helps to formulate specific recommendations to address families' reluctance to vaccinate. Improving the communication skills and resources of health care staff to deal with people with some form of reluctance emerges as the main potential area for intervention, which is consistent with other studies.<a class="elsevierStyleCrossRef" href="#bb0075">15</a>,<a class="elsevierStyleCrossRef" href="#bb0150">30</a> Furthermore, more than 50% of paediatric professionals in one city express an interest in receiving training in this area.<a class="elsevierStyleCrossRef" href="#bb0095">19</a> The NHS should increase the quantity and quality of information it offers on vaccines, with contents and formats that adequately respond to the needs and doubts of this type of user.Ethical responsibilitiesThe work described was carried out by the authors in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). The participants have received written information about the study and have given their informed consent. Voluntary participation, anonymity and data protection have been ensured.This research was approved by the Ethics Committee for Research with Medicines of the Parc de Salut MAR (Barcelona).FundingNone.Conflict of interestsNone.Key insights<ul class="elsevierStyleList" id="l0005"><li class="elsevierStyleListItem" id="li0005">•What is known about the issue?</li></ul>To address vaccine reluctance, it is necessary to understand the reasons why people are dissatisfied with vaccines. Most vaccination depends on the decision of those responsible for infants. There is insufficient evidence on their views in our context.<ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="li0010">•What does the study add to the literature?</li></ul>This study provided insight into the views of mothers of infants aged 0–7 years, some of their reluctant practices and underlying reasons, and identified some recommendations for improvement.<ul class="elsevierStyleList" id="l0015"><li class="elsevierStyleListItem" id="li0015">•What are the implications of the results obtained?</li></ul>Improving the resources of health services and the skills of paediatric teams to respond to reluctant people in consultation emerges as the main field of intervention." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1855516" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1613241" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1855515" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1613242" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "s0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "s0010" "titulo" => "Material and methods" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "s0015" "titulo" => "Design" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "s0020" "titulo" => "Scope and study population" ] 1 => array:2 [ "identificador" => "s0025" "titulo" => "Sampling" ] 2 => array:2 [ "identificador" => "s0030" "titulo" => "Data collection" ] 3 => array:2 [ "identificador" => "s0035" "titulo" => "Data analysis and quality" ] 4 => array:2 [ "identificador" => "s0040" "titulo" => "Ethical aspects" ] ] ] ] ] 6 => array:3 [ "identificador" => "s0045" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "s0050" "titulo" => "Health services factors" ] 1 => array:2 [ "identificador" => "s0055" "titulo" => "Specific vaccination factors" ] 2 => array:2 [ "identificador" => "s0060" "titulo" => "Individual and group factors" ] 3 => array:2 [ "identificador" => "s0065" "titulo" => "Contextual factors: COVID-19 pandemic" ] 4 => array:2 [ "identificador" => "s0070" "titulo" => "Suggestions" ] ] ] 7 => array:2 [ "identificador" => "s0075" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "s0080" "titulo" => "Limitations" ] 9 => array:2 [ "identificador" => "s0085" "titulo" => "Conclusions and recommendations" ] 10 => array:2 [ "identificador" => "s0090" "titulo" => "Ethical responsibilities" ] 11 => array:2 [ "identificador" => "s0095" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "s1005" "titulo" => "Conflict of interests" ] 13 => array:2 [ "identificador" => "s0100" "titulo" => "Key insights" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-05-30" "fechaAceptado" => "2022-08-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1613241" "palabras" => array:5 [ 0 => "Vaccines" 1 => "Vaccine hesitancy" 2 => "Parenting" 3 => "Qualitative research" 4 => "Public health" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1613242" "palabras" => array:5 [ 0 => "Vacunas" 1 => "Reticencia vacunal" 2 => "Responsabilidad parental" 3 => "Investigación cualitativa" 4 => "Salud pública" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo describe the opinions regarding vaccination of parents of infants aged 0–7 years in Barcelona with different profiles of vaccine hesitancy; to describe the elements contributing to hesitancy; and to explore suggestions for improvement. Materials and methodsQualitative exploratory-descriptive and phenomenological study. Thirteen semi-structured individual interviews were carried out with parents of infants with vaccine hesitancy (12 mothers and one father). A thematic content analysis was performed. Data quality was ensured through triangulation strategies. ResultsAmong the elements contributing to vaccine hesitancy, the participants highlighted the scarce information on vaccines provided by the health system, the variability in the treatment received at the consultation and their need to make informed decisions. Insufficient information contributes to their perception that the vaccination schedule is excessive, premature and rigid, and to the low risk perception of some diseases. Although they report trust in health services, many complement it with private or non-biomedical services. Mothers considered that the COVID-19 pandemic had little influence on their hesitancy. ConclusionsThe hesitancy identified among the informants is attributed to the lack of information provided by the health services, the communication and treatment received at the consultation and unresolved doubts regarding the vaccination schedule. It is recommended to increase the skills of the professional teams to improve communication with parents of infants and to increase the quality of the information provided by the National Health System." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosDescribir las opiniones respecto a la vacunación de las personas responsables de los cuidados de infantes de 0–7 años en Barcelona con diferentes perfiles de reticencia vacunal; describir los elementos que contribuyen a la reticencia y explorar sugerencias de mejora. Materiales y métodosEstudio cualitativo exploratorio–descriptivo y fenomenológico. Se realizaron 13 entrevistas individuales semiestructuradas con responsables de infantes con reticencia vacunal (12 madres y un padre). Se efectuó un análisis temático del contenido. La calidad de los datos se garantizó mediante estrategias de triangulación. ResultadosEntre los elementos que contribuyen a la reticencia vacunal, las participantes destacaron la escasa información sobre vacunas aportada por el sistema sanitario, la variabilidad en el trato recibido en la consulta y su necesidad de tomar decisiones informadas. La información insuficiente contribuye a su percepción de que el calendario vacunal es excesivo, precoz y rígido, y a la baja percepción del riesgo de algunas enfermedades. Aunque reportan confianza en los servicios sanitarios, muchas lo complementan con servicios privados o no-biomédicos. Las madres consideraban que la pandemia de COVID-19 había tenido escasa influencia en su reticencia. ConclusionesLa reticencia identificada entre las informantes se atribuye a la falta de información aportada por los servicios sanitarios, a la comunicación y el trato recibido en la consulta y a las dudas no resueltas respecto al calendario vacunal. Se recomienda incrementar las habilidades de los equipos profesionales para mejorar la comunicación con las personas responsables de infantes y aumentar la calidad de la información que ofrece el Sistema Nacional de Salud." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez-Peña L, Porthé V, Asensio A, Diez È. Reticencia vacunal: opinión de las personas responsables de los cuidados de infantes en Barcelona. Vacun. 2022. https://doi.org/10.1016/j.vacun.2022.08.003" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<elsevierMultimedia ident="ec0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "s0105" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "t0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Code \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level of education<a class="elsevierStyleCrossRef" href="#tf1000">a</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of children \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age of children \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vaccine schedule<a class="elsevierStyleCrossRef" href="#tf2000">b</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Interview format \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HU-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete, con dudas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Online \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">InCompleteporretraso \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2, 4 and 10 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete, with doubts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Online \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incomplete due to delay and rejection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete with delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Online \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete with delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 years and 9 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete with delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incomplete due to rejection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incomplete due to delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incompledue to rejection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS-4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Online \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete with delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MU-8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Graduate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incomplete due to delay and rejection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Face to face \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tf1000" "etiqueta" => "a" "nota" => "The categorisation used in the Barcelona Health Survey (ESB<a class="elsevierStyleCrossRef" href="#bb0045">9</a> for its initials in Spanish) was followed. Secondary: includes Vocational Training. Graduates: includes PhD." ] 1 => array:3 [ "identificador" => "tf2000" "etiqueta" => "b" "nota" => "The vaccination schedule has been established at the discretion of the authors. Complete: they have given all the vaccines in the schedule. Incomplete: they have not included all of them. Nil: none of the vaccines have been administered, nor do they plan to do so in the near future. Delayed: according to the time criteria established in the schedule." ] ] ] "descripcion" => array:1 [ "en" => "Sociodemographic characteristics of participants." ] ] 1 => array:8 [ "identificador" => "t0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Health service factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TreatmentThe paediatrician told us: “I spend time with you because I know you want to vaccinate, but if you don't... I'm leaving, I don't want to know anything! (HU-1)“In fact, I have sometimes avoided public health care so as not to feel questioned, so that I wouldn't be treated badly” (MU-2).I think it depends on which professionals you go to when you ask about vaccines, if they see you with doubts, you get very bad treatment (...) Maybe you just want information and if they treat you like that you say... “well, forget about the vaccine” (MU-2). “The professionals] generate a bit of stress... the baby may be crying... and the nurse continues to do things... at some point I had to stop and say “Wait a minute, he's crying!” (MU-3)“I found the paediatrician that I needed for myself, because she didn't pressure me, she respected my decision... and I saw her to be in favour of... she wasn't going to judge or refute what I said, or the decision that I was going to make” (MS-4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Communication“I feel that [the professionals] sometimes feel uncomfortable when you ask them questions” (MU-4).“The doctor we have explains everything very technically, (...) your technical language is not the same as ours” (MS-1).“There is no kind of sensitivity about possible doubts... or information about components, side effects, what the point of the vaccine is, why so many doses, why the ages (...) It seems to me that there is no space for patient information and decision” (MS-3).“They don't give me the answer I need... I don't understand it, it is not enough, it is very superficial, they don't help me... so I go to someone who can help me” (MU-5).“I have had to make some visits to private doctors. Because they tell you one thing, but sometimes you don't quite believe it, and you don't see another doctor... you want another opinion” (MS-1). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specific vaccination factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lack of information about vaccines and their characteristics“My mother-in-law] told me that [vaccines] had a lot of heavy metals, which the liver or the kidney cannot absorb well” (MS-1).“There has been controversy with some that have egg in them that, if you haven't introduced it in the diet, then they can respond to egg... or be allergic or intolerant” (MU-8)“Maybe the body is not ready at that time. A month after birth... it is a body that still has to be formed, it has to be immunised, it has to become strong... and we are injecting it with a virus? What for?” (MS-4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">“Papilloma] is a relatively new vaccine, there has been talk of side effects, and well, there is a lack of information when a new vaccine comes out when it comes to reassuring parents” (MS-2)I will certainly vaccinate her [against hepatitis B] because it is something that is not dangerous for my daughter now, but when she gets a few years older it could become dangerous” (MS-4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccination schedulePrecocity: “I think this is the issue, that he is a baby. It's not so much that I don't believe in vaccines, I've always been vaccinated, but rather that it's such a small baby (...) he doesn't even talk. We can't help him anyway!” (MU-1)Excess: “I agree with all the vaccines, but I don't think it's necessary to give him 4 vaccines all at once in the months, for reasons of humanity [many jabs] and because it can cause a reaction” (MS-2).Rigidity: “It's good to study each case... each child with their characteristics, life rhythms, medical history... To study them in order to adapt their vaccination a bit, instead of making such a generic vaccination for the whole population” (MU-2). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Individiual and group factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for information for decision-making“We still have a lot of doubts... because with other things we have always had a very clear opinion about what we wanted to do, but with this we are finding it very difficult” (MU-1).“With the issue of my children I try to inform myself a lot, because I think that information is power and if you don't go with your information beforehand, they don't tell you [the professionals or the care system]” (MS-2).“It is good that we have information so that we can make a decision, to take something based on what you have been able to inform yourself and read. It happens with education too, when you go to look for a school you get information and you look, and if you are going to buy a car too... or a house...” (MU-8). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Risk perception[He is making a metaphor between the organism and an operating system] “It's like, you instal a lot of things in your device that you will only use 4 of them” (HU-1) [He is creating a metaphor between the organism and an operating system].“A chicken pox or measles that nowadays with the medical innovations that exist, if you catch them, you wouldn't die. And many people used to die of measles” (MU-7).“I don't consider chickenpox in particular to be a serious disease, from my own knowledge. Before they didn't vaccinate and now they do” (MU-4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paradigm of health “We do look for a bit of an alternative before going for pharmaceutical chemical medication. It is there and it is important to take it when it is necessary” (MU-8).“I relied a lot on my full confidence in the homoeopath who had been monitoring my son since he was one and a half years old. He always told me to do what I wanted, but he believed that some vaccines are more important than others” (MS-3). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Contextual factors: COVID-19 pandemic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">“I think that if the context was not a pandemic I would have made the same decision. Because in the end it is a decision based on a particular way of understanding medicine” (MU-5).“The current context of COVID makes people decide not to vaccinate; I understand that, if you stay at home, there will be many people who will say ‘I don't vaccinate’“(MU-1). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Verbatims from participants in keeping with the categories and factors of analysis." ] ] 2 => array:8 [ "identificador" => "t0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Receive more information about vaccination“Hold sessions where they explain what we are vaccinating about, what the vaccines are for, why it is important to follow this schedule and why not.... Information that is as objective as possible” (MU-3)“I would like them to provide more information about what we are giving our children. What they are for, what they are necessary for, what they help us with and what we prevent. Don't take everything for granted. To give clear and truthful information” (MS-2)“A course like this [with information about vaccinations] can be done easily in the public health system, just like a course on childbirth or breastfeeding. It can even be done before [infants] are born, because pregnant women have a lot of free time!” (MU-1)Information adapted to the needs of responsible persons“They should really prepare people according to what they feel. According to their belief. Because beliefs are valid. They are our beliefs and we have to respect them. A doctor should prepare parents to choose what they believe is right for their children” (MS-4).Midwives as agents for providing information“Perhaps it would be good if the one who would transmit this information in a more relaxed way were the midwives, the ones who have controlled your pregnancy and also control your postpartum” (HU-1). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Suggestions from respondents about improving the approach to reluctance to use health services." ] ] 3 => array:7 [ "identificador" => "ec0005" "etiqueta" => "Supplementary material" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0020" "detalle" => "Supplementary materia" "rol" => "short" ] ] "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 13570 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bb0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ten Great Public Health Achievements at United States (2001–2010)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Centers for Disease Control. Domestic Public Health Achievements Team" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:2 [ "link" => "https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm" "fecha" => "2011" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bb0010" "etiqueta" => "2." 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"fecha" => "2015" "volumen" => "33" "numero" => "34" "paginaInicial" => "4161" "paginaFinal" => "4164" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25896383" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bb0025" "etiqueta" => "5." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catalogue of interventions addressing vaccine hesitancy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "European Centre for Disease Prevention and Control" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:2 [ "link" => "https://ecdc.europa.eu/sites/portal/files/documents/Catalogue-interventions-vaccine-hesitancy.pdf" "fecha" => "2017" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bb0030" "etiqueta" => "6." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolución coberturas de primovacunación. España 2008–2018" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Ministerio de Sanidad. Dirección General de Salud Pública" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:2 [ "link" => "https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/calendario-y-coberturas/coberturas/docs/Tabla1.pdf" "fecha" => "2018" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bb0035" "etiqueta" => "7." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Quaderns de la bona praxi" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Campins" 1 => "J. Arimany-Manso" 2 => "J. 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Vaccine hesitancy: Opinion of people responsible for the care of infants in Barcelona

Reticencia vacunal: opinión de las personas responsables de los cuidados de infantes en Barcelona

Iago Rodríguez-Peñaa,e,f,

Corresponding author

irodrigu@aspb.cat

Corresponding author.

, Victoria Porthéa,b, Alba Asensioa, Èlia Dieza,b,c,d

a Agència de Salut Pública de Barcelona, Barcelona, Spain

b Centro de Investigación Biomédica en Red Epidemiología y Salud Pública (CIBERESP), Madrid, Spain

c Institut d'Investigació Biomèdica (IBB Sant Pau), Barcelona, Spain

d Departamento de Ciencias Experimentales y de la Salud, Universitat Pompeu Fabra, Barcelona, Spain

e Universitat Pompeu Fabra, Barcelona, Spain

f Universitat Autònoma de Barcelona, Barcelona, Spain

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        "titulo" => "Reticencia vacunal&#58; opini&#243;n de las personas responsables de los cuidados de infantes en Barcelona"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Vaccination prevents between 2 and 3 million deaths per year worldwide and is one of the most cost-effective preventive strategies&#46;<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> However&#44; the World Health Organisation &#40;WHO&#41; lists vaccine reluctance as one of the major threats to global health&#46;<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> Vaccine reluctance is defined as refusal&#44; hesitancy or delay in vaccination&#44; a complex and context-dependent phenomenon that can compromise population health&#46; It ranges from hesitant acceptance of all vaccines to complete refusal to late acceptance and partial refusal&#46;<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">The WHO Expert Group on Immunisation SAGE&#41;<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> classifies the determinants of reluctance into&#58; 1&#41; contextual factors&#44; including the media and its media outreach and socio-economic and cultural elements&#44; 2&#41; individual and group factors&#44; encompassing beliefs about vaccines&#44; risk perception and social norm&#44; among others&#59; and 3&#41; vaccination-specific factors&#44; including vaccine characteristics and schedule of administration&#46;<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">In order to formulate effective interventions against reluctance&#44; it is necessary to understand the context&#44; determinants and challenges in each territory&#46;<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a> In Spain&#44; although vaccination is not compulsory&#44; coverage reaches 97&#37; for most of the vaccines on the routine vaccination schedule&#46;<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> The few surveys available<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a> estimate that 10&#37;&#8211;15&#37; of the population is reluctant to be vaccinated&#44; although in the 2016 Barcelona Health Survey &#40;BHS&#41;&#44; only 1&#46;5&#37; of minors were not vaccinated for non-medical reasons&#46;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">Although reluctance is not a current threat to public health in Spain&#44; there are doubts about vaccination in some sectors of the population&#44; including some health professionals&#44; and the growing trend of the media effect of the anti-vaccine movement is a concern for future collective health&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a></p><p id="p0025" class="elsevierStylePara elsevierViewall">Given that most of the vaccines on the routine vaccination schedule &#40;free of charge in our context&#41; are administered at paediatric age and that the decision to vaccinate falls to the people responsible for the children &#40;mainly mothers&#44; fathers or legal guardians&#41;&#44; it is of interest to know their opinions in depth in order to guide interventions to address this phenomenon&#46; Reluctance has been studied in several contexts&#44;<a class="elsevierStyleCrossRefs" href="#bb0055"><span class="elsevierStyleSup">11&#8211;13</span></a> but in our setting we have little information on the opinions and knowledge of those responsible for infants&#46; In addition&#44; the COVID-19 pandemic has highlighted both the importance of vaccination in the control of communicable diseases and the challenge of vaccine reluctance&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">This study therefore aims to&#58; a&#41; describe the views on vaccination of caregivers of infants aged 0&#8211;7&#8239;years with different profiles of vaccine reluctance in Barcelona&#59; b&#41; describe the elements contributing to vaccine reluctance&#59; and c&#41; explore suggestions and proposals to reduce reluctant practices&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Material and methods</span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Design</span><p id="p0035" class="elsevierStylePara elsevierViewall">A qualitative exploratory-descriptive phenomenological study&#46;</p><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Scope and study population</span><p id="p0040" class="elsevierStylePara elsevierViewall">the fieldwork was conducted in Barcelona between January and March 2021&#46; The study population were the people responsible for the care of one or more infants aged 0 to 7&#8239;years&#44; resident in the city and who expressed some type of vaccine reluctance&#46; Different profiles of reluctance were included&#58; acceptance with hesitation&#44; delay and refusal of some or all vaccines&#46; Those who expressed extreme refusal were excluded because they tend to be unresponsive to dialogue&#46;<a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Sampling</span><p id="p0045" class="elsevierStylePara elsevierViewall">Theoretical&#44; maximum variation for gender&#44; age and educational level&#46; Segmentation criteria were based on the district of residence&#44; selecting one high-income and one low-income district&#44; to include possible aspects related to inequality&#46; Recruitment was made through posters in public spaces and information on social networks&#44; mainly WhatsApp&#46; The main sampling strategy was snowballing&#46; Given the difficulty in accessing the population residing in these districts&#44; because they represent a low percentage of the population and because of the pandemic&#44; district was eliminated as a segmentation criterion in the final design&#46; The final sample included 13 participants residing in Barcelona&#46; The majority were first-time mothers&#44; aged 30&#8211;40&#8239;years&#44; with secondary or university education&#44; children aged 2&#8239;months to 7&#8239;years and with the intention to vaccinate&#44; although with doubts&#44; delay or partial refusal &#40;<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#41;&#46; In the description of the results&#44; we will use the generic female to refer to all the people interviewed&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Data collection</span><p id="p0050" class="elsevierStylePara elsevierViewall">Semi-structured individual interviews &#40;average length 45&#8239;min&#41; were conducted with a script that explored the factors defined by SAGE&#46;<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> Due to the pandemic&#44; participants were offered a variety of interview formats&#58; face-to-face&#44; online or telephone&#46; Most were conducted non-face-to-face&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">Data analysis and quality</span><p id="p0055" class="elsevierStylePara elsevierViewall">The interviews were audio-recorded and then transcribed&#46; Thematic analysis was carried out using Atlas&#46;ti software&#46; The categories of analysis were generated from the script and from the analysis of the information&#44; through constant comparison of the data&#46; To ensure rigour and quality of information&#44; data were triangulated between researchers &#40;IR&#44; AA&#44; VP&#41; and with the literature&#46;</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">Ethical aspects</span><p id="p0060" class="elsevierStylePara elsevierViewall">participants received written information about the study and gave informed consent&#46; Voluntary participation&#44; anonymity and data protection were ensured&#46; An identification code including number&#44; gender and level of education was assigned&#46; This study has the approval of the Ethics Committee of ParcSalut MAR &#40;2021&#47;10136&#41;&#46;</p></span></span></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0105">Results</span><p id="p0065" class="elsevierStylePara elsevierViewall">The description of the results is inspired by the SAGE<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> framework&#58; contextual&#44; individual-group&#44; and vaccination-specific factors&#46; However&#44; factors related to health services emerged strongly from the analysis&#44; which&#44; although considered vaccination-specific in the framework&#44; led to the creation of a new category that was analysed separately&#46; The results refer to public health services and are otherwise specified&#46; Due to space limitations&#44; most of the citations are collected in <a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0110">Health services factors</span><p id="p0070" class="elsevierStylePara elsevierViewall">Two issues related to the interaction between health professionals and users emerge from the discourse&#58; the treatment received and communication&#46; With regard to treatment&#44; mothers state that expressing their doubts or rejection of vaccines in the consultation room may condition the professional treatment received&#46; Some mothers report uncomfortable&#44; derogatory or aggressive experiences&#58; &#8220;Let&#39;s see&#44; but do you understand that you have to vaccinate&#44; that you can&#39;t go around with your child unvaccinated&#8221;&#44; MU-1&#46; Several reported feeling pressured to vaccinate&#44; sometimes through fear-mongering discourse&#44; &#8220;Most of the times I have suggested an alternative&#44; the response has been to scare me&#44; like&#58; &#8216;Be careful&#44; don&#39;t leave the fold&#8217;&#8221;&#44; MU-4&#46; However&#44; they also point out a certain variability in the professional treatment&#44; referring to positive experiences associated with an understanding attitude&#44; &#8220;The staff who attended us told us&#58; &#8220;There is no problem&#44; it is your criteria&#8221;&#8221;&#44; MU-1&#46;</p><p id="p0075" class="elsevierStylePara elsevierViewall">With regard to communication&#44; all the participants consider that the information received from the health services is scarce&#44; &#8220;They gave me a DIN-A4 sheet of paper on one side&#44; with 4 things on it with the first vaccination&#46; That is not informing the patient&#8221;&#44; MU-8&#46; Moreover&#44; it is not provided in advance and some mothers are caught unawares&#46; When they ask for more information&#44; the information they receive seems insufficient and&#47;or complex&#46; They point out that the lack of time in the consultation room and the rigidity of the technical discourse produce a feeling of standardisation that worsens professional-user communication&#46;</p><p id="p0080" class="elsevierStylePara elsevierViewall">The little information they receive from the health services&#44; added to the treatment that they sometimes consider to be lackadaisical&#44; causes these mothers to delay or partially refuse vaccination while they seek the information they do not obtain from the services&#58; &#8220;Since the information does not come to you&#44; let&#39;s go and look for it&#8221;&#44; MU-1&#46; Sometimes they seek a second medical opinion&#44; generally from the private sector&#44; or they turn to non-biomedical professionals who become references and many of them advocate reticence&#46;</p></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0115">Specific vaccination factors</span><p id="p0085" class="elsevierStylePara elsevierViewall">A lack of information about vaccines and their characteristics is identified in the mothers&#39; discourse&#44; which is evident in the lack of knowledge about the vaccines most recently incorporated into the schedule&#44; the belief in supposedly harmful components present in vaccines &#40;egg or mercury&#41;&#44; or their supposed association with autism&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">This also seems to influence the mothers&#39; perception of the vaccination schedule&#44; which arouses distrust in 3 aspects&#58; the start&#44; the number of vaccines and their application&#46; They report that the first vaccinations are given at a very early age&#44; and this increases the fear of adverse effects&#44; including mild ones such as fever&#46; Many mothers believe that the immune system in the first months of life is fragile and not ready to receive vaccines&#58; &#8220;It seems to me that it starts too early and that at 2 months they are super small&#8221; MU-5&#46; In addition&#44; they consider that too many vaccines are given in too short a time&#46; They are concerned about combined vaccines&#44; especially hexavalent vaccines&#44; because they do not allow them to choose the antigens separately&#46;</p><p id="p0095" class="elsevierStylePara elsevierViewall">The majority of mothers express the desire to apply a vaccination schedule adapted to their needs&#46; They give as examples the situation of infants who will not attend nursery school before their first birthday or those who&#44; particularly during the COVID-19 pandemic&#44; have been at home in the care of relatives&#58; &#8220;With the current context of confinement&#44; the child is in a bubble&#8221;&#44; MU-1&#41;&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">In this way&#44; the lack of information contributes to the perception of a schedule that is far removed from their needs and contributes to mothers delaying or refusing certain vaccinations&#46;</p></span><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0120">Individual and group factors</span><p id="p0105" class="elsevierStylePara elsevierViewall">From this discourse&#44; some common individual components are identified among the participants&#46; In general&#44; respondents express their need to be well-informed in order to make decisions and value information about vaccines because it provides them with autonomy and empowerment&#46; They also need enough time to decide&#44; and demand less pressure and more sensitivity on the part of health staff to the emotional burden of deciding about their children&#39;s health&#46; These mothers express difficulties in forming a clear opinion about vaccines and perceive vaccination as an uncertain issue that makes them hesitant&#46; They state that this is also contributed to by what the media says and the polarised positions of consultation sources&#44; mainly on the Internet&#46;</p><p id="p0110" class="elsevierStylePara elsevierViewall">Other factors that emerge from the discourse relate to the perception of risk and the health paradigm&#46; The risk&#8211;benefit comparison between vaccinating and not vaccinating emerges&#58; &#8220;I think both options are a risk&#8221;&#44; MU-2&#46; In addition&#44; some mothers believe that vaccine-preventable diseases are unlikely&#44; eradicated or not very serious in our environment&#46; On the other hand&#44; while most report confidence in the biomedical paradigm on which health services are based&#44; they criticise over-medicating and the lack of consideration of the specificities of each person in the health-disease processes&#46; Some mothers turn to alternative paradigms &#40;homoeopathy&#44; etc&#46;&#41; as a complement and leave the mainstream system as a last resort&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">As a result&#44; some mothers who feel that they do not have the information they need to make decisions end up delaying their infants&#39; vaccination&#46; Low risk perception of some diseases and adherence to alternative health paradigms contribute to mistrust of vaccination and reluctant practices&#46;</p></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0125">Contextual factors&#58; COVID-19 pandemic</span><p id="p0120" class="elsevierStylePara elsevierViewall">Because of the context in the study period&#44; the effect of the COVID-19 pandemic and the media coverage of its vaccine development was explored&#46; Most mothers felt that the development of COVID-19 vaccines had had little influence because it was a different issue and&#44; in all cases&#44; their reluctance preceded the pandemic&#46;</p></span><span id="s0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0130">Suggestions</span><p id="p0125" class="elsevierStylePara elsevierViewall">The interviews collected suggestions from respondents generally addressed to public health services &#40;<a class="elsevierStyleCrossRef" href="#t0015">Table 3</a>&#41;&#46; Most of them urged for information provided by the services to be improved&#44; so that they would provide more information about vaccination and more tailored to the needs of those responsible for children&#58; &#8220;More information and less invasion&#8221;&#44; MU-8&#46;</p><elsevierMultimedia ident="t0015"></elsevierMultimedia></span></span><span id="s0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0135">Discussion</span><p id="p0130" class="elsevierStylePara elsevierViewall">The reluctance among this study&#39;s participants consists mainly of doubts&#44; delays in first vaccinations of the schedule and refusal of some vaccinations&#46; The main factors associated with these practices are the lack of information provided by the health services&#44; the communication and treatment received at the health centre and individual doubts regarding the vaccination schedule&#46;</p><p id="p0135" class="elsevierStylePara elsevierViewall">The SAGE model was conceived with the aim of defining the main factors influencing vaccine reluctance at a global level&#44; but in specific contexts specificity is lost&#46; In our study&#44; factors related to health services emerged so strongly that they led to the creation of a specific category for such information&#46; This is consistent with the context in Spain&#44; where National Health System &#40;NHS&#41; health teams are key in access to vaccination and are the main source of information that may influence vaccine reluctance&#46;<a class="elsevierStyleCrossRefs" href="#bb0075"><span class="elsevierStyleSup">15&#8211;17</span></a> Other factors such as contextual factors&#44; contrary to expectations&#44; were hardly mentioned&#46;</p><p id="p0140" class="elsevierStylePara elsevierViewall">The lack of information on vaccination provided by public health services&#44; accentuated by poor communication with paediatric professionals&#44; with little time for each consultation&#44; makes it difficult to form a clear opinion on vaccines&#44; generates doubts and hinders decision-making on the vaccination of children&#46;<a class="elsevierStyleCrossRef" href="#bb0075"><span class="elsevierStyleSup">15</span></a> Although most mothers recognised the importance of vaccines&#44; some of the unresolved concerns called into question their decision to vaccinate&#46; Extensive and rigorous information now exists that could address these concerns&#59; however&#44; it does not appear to be effectively or convincingly communicated to some families&#46;<a class="elsevierStyleCrossRef" href="#bb0090"><span class="elsevierStyleSup">18</span></a> Part of these results could be explained by the lack of capacity to answer doubts expressed by 29&#37; of paediatricians&#46;<a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a> On the other hand&#44; the mistrust of health services generated by the treatment received in the consultation room is consistent with studies that highlight the importance of respectful treatment and good communication to address reluctance in the consultation room&#46;<a class="elsevierStyleCrossRef" href="#bb0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0100"><span class="elsevierStyleSup">20</span></a></p><p id="p0145" class="elsevierStylePara elsevierViewall">In contrast to another study conducted in Spain&#44;<a class="elsevierStyleCrossRef" href="#bb0065"><span class="elsevierStyleSup">13</span></a> in our results the move away from medicalisation and the prioritisation of &#8220;natural processes&#8221; does not appear as a relevant factor for reluctance&#46; Instead&#44; the non-biomedical paradigm emerges as a solution to the manifest dissatisfaction of some mothers&#44; which is consistent with a study that indicates that reluctant people are more likely to distrust conventional sources and their information&#46;<a class="elsevierStyleCrossRef" href="#bb0080"><span class="elsevierStyleSup">16</span></a></p><p id="p0150" class="elsevierStylePara elsevierViewall">The willingness of these mothers to take an active part in the health of their infants and to make informed decisions is consistent with the new role that users are assuming in their relationship with health services&#58; the active patient&#46;<a class="elsevierStyleCrossRef" href="#bb0105"><span class="elsevierStyleSup">21</span></a> This patient is characterised by seeking optimal quality of care that allows them to establish a link with professional teams based on deliberation and empowerment as a patient&#44; so that they can take proper responsibility for their health&#46; This patient profile is positively associated with the level of education&#44; so that the higher the level of education&#44; the greater the responsibility for one&#39;s own health care&#46;</p><p id="p0155" class="elsevierStylePara elsevierViewall">The lack of information on vaccines could partly explain these mothers&#39; perception of the vaccination schedule and their desire to adapt it to their needs&#46; Previous studies point to an increase in parents using an alternative schedule in recent decades due to concerns about some routine vaccines&#46;<a class="elsevierStyleCrossRef" href="#bb0090"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0110"><span class="elsevierStyleSup">22</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0115"><span class="elsevierStyleSup">23</span></a> Other studies also point out that vaccine-averse individuals are concerned about vaccine safety&#44; while pro-vaccination individuals prioritise disease prevention&#46;<a class="elsevierStyleCrossRefs" href="#bb0120"><span class="elsevierStyleSup">24&#8211;26</span></a></p><p id="p0160" class="elsevierStylePara elsevierViewall">Contrary to expectations&#44; the development of COVID-19 vaccines during the study period was hardly relevant&#46; In the case of these mothers&#44; reluctance preceded the pandemic and the rapid development of vaccines did not influence the decision to vaccinate&#46; However&#44; it should be remembered that the interviews were conducted before the start of the population vaccination campaign against COVID-19 and the episodes of pharmacovigilance on some vaccines that generated media alarm&#46;<a class="elsevierStyleCrossRef" href="#bb0135"><span class="elsevierStyleSup">27</span></a> The impact of the pandemic on routine vaccination will need to be assessed at a later stage&#46;</p></span><span id="s0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0140">Limitations</span><p id="p0165" class="elsevierStylePara elsevierViewall">One limitation of the study is the homogeneity of the sample&#58; first time mothers&#44; aged 30 to 40&#8239;years&#44; with secondary or graduate education and with a certain intention to vaccinate&#46; This sample does not allow conclusions to be drawn regarding other socio-demographic variables that influence reluctance to vaccinate&#44; such as socio-economic level&#46;<a class="elsevierStyleCrossRef" href="#bb0140"><span class="elsevierStyleSup">28</span></a> The low male participation denotes the persistence of gender roles in caregiving&#58; mothers are primarily responsible for the health of their children&#59; the results are consistent with a similar study in the Spanish population&#46;<a class="elsevierStyleCrossRef" href="#bb0145"><span class="elsevierStyleSup">29</span></a> Another possible limitation derives from the format of the interviews&#46; The telematic format may have conditioned communication and the links established between the interviewer and the interviewee&#46; However&#44; the interviews were conducted one year into the pandemic&#44; when a large part of the population with this socio-demographic profile had become familiar with virtual communication&#46;</p></span><span id="s0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0145">Conclusions and recommendations</span><p id="p0170" class="elsevierStylePara elsevierViewall">The reluctance identified among participants is mainly attributed to the lack of information provided by the health services&#44; to the communication and treatment received at the consultation and to unresolved doubts regarding the vaccination schedule&#46;</p><p id="p0175" class="elsevierStylePara elsevierViewall">This study helps to formulate specific recommendations to address families&#39; reluctance to vaccinate&#46; Improving the communication skills and resources of health care staff to deal with people with some form of reluctance emerges as the main potential area for intervention&#44; which is consistent with other studies&#46;<a class="elsevierStyleCrossRef" href="#bb0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0150"><span class="elsevierStyleSup">30</span></a> Furthermore&#44; more than 50&#37; of paediatric professionals in one city express an interest in receiving training in this area&#46;<a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a> The NHS should increase the quantity and quality of information it offers on vaccines&#44; with contents and formats that adequately respond to the needs and doubts of this type of user&#46;</p></span><span id="s0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0150">Ethical responsibilities</span><p id="p0180" class="elsevierStylePara elsevierViewall">The work described was carried out by the authors in accordance with the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46; The participants have received written information about the study and have given their informed consent&#46; Voluntary participation&#44; anonymity and data protection have been ensured&#46;</p><p id="p0185" class="elsevierStylePara elsevierViewall">This research was approved by the Ethics Committee for Research with Medicines of the Parc de Salut MAR &#40;Barcelona&#41;&#46;</p></span><span id="s0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0155">Funding</span><p id="p0190" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="s1005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0165">Conflict of interests</span><p id="p0230" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="s0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0160">Key insights</span><p id="p0195" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0005"><li class="elsevierStyleListItem" id="li0005"><span class="elsevierStyleLabel">&#8226;</span><p id="p0200" class="elsevierStylePara elsevierViewall">What is known about the issue&#63;</p></li></ul></p><p id="p0205" class="elsevierStylePara elsevierViewall">To address vaccine reluctance&#44; it is necessary to understand the reasons why people are dissatisfied with vaccines&#46; Most vaccination depends on the decision of those responsible for infants&#46; There is insufficient evidence on their views in our context&#46;<ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="li0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0210" class="elsevierStylePara elsevierViewall">What does the study add to the literature&#63;</p></li></ul></p><p id="p0215" class="elsevierStylePara elsevierViewall">This study provided insight into the views of mothers of infants aged 0&#8211;7&#8239;years&#44; some of their reluctant practices and underlying reasons&#44; and identified some recommendations for improvement&#46;<ul class="elsevierStyleList" id="l0015"><li class="elsevierStyleListItem" id="li0015"><span class="elsevierStyleLabel">&#8226;</span><p id="p0220" class="elsevierStylePara elsevierViewall">What are the implications of the results obtained&#63;</p></li></ul></p><p id="p0225" class="elsevierStylePara elsevierViewall">Improving the resources of health services and the skills of paediatric teams to respond to reluctant people in consultation emerges as the main field of intervention&#46;</p></span></span>"
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            1 => "Reticencia vacunal"
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        "titulo" => "Abstract"
        "resumen" => "<span id="as0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Objectives</span><p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">To describe the opinions regarding vaccination of parents of infants aged 0&#8211;7&#8239;years in Barcelona with different profiles of vaccine hesitancy&#59; to describe the elements contributing to hesitancy&#59; and to explore suggestions for improvement&#46;</p></span> <span id="as0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Materials and methods</span><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Qualitative exploratory-descriptive and phenomenological study&#46; Thirteen semi-structured individual interviews were carried out with parents of infants with vaccine hesitancy &#40;12 mothers and one father&#41;&#46; A thematic content analysis was performed&#46; Data quality was ensured through triangulation strategies&#46;</p></span> <span id="as0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Results</span><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">Among the elements contributing to vaccine hesitancy&#44; the participants highlighted the scarce information on vaccines provided by the health system&#44; the variability in the treatment received at the consultation and their need to make informed decisions&#46; Insufficient information contributes to their perception that the vaccination schedule is excessive&#44; premature and rigid&#44; and to the low risk perception of some diseases&#46; Although they report trust in health services&#44; many complement it with private or non-biomedical services&#46; Mothers considered that the COVID-19 pandemic had little influence on their hesitancy&#46;</p></span> <span id="as0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Conclusions</span><p id="sp0045" class="elsevierStyleSimplePara elsevierViewall">The hesitancy identified among the informants is attributed to the lack of information provided by the health services&#44; the communication and treatment received at the consultation and unresolved doubts regarding the vaccination schedule&#46; It is recommended to increase the skills of the professional teams to improve communication with parents of infants and to increase the quality of the information provided by the National Health System&#46;</p></span>"
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            "titulo" => "Materials and methods"
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          2 => array:2 [
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        "resumen" => "<span id="as0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Objetivos</span><p id="sp0050" class="elsevierStyleSimplePara elsevierViewall">Describir las opiniones respecto a la vacunaci&#243;n de las personas responsables de los cuidados de infantes de 0&#8211;7 a&#241;os en Barcelona con diferentes perfiles de reticencia vacunal&#59; describir los elementos que contribuyen a la reticencia y explorar sugerencias de mejora&#46;</p></span> <span id="as0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Materiales y m&#233;todos</span><p id="sp0055" class="elsevierStyleSimplePara elsevierViewall">Estudio cualitativo exploratorio&#8211;descriptivo y fenomenol&#243;gico&#46; Se realizaron 13 entrevistas individuales semiestructuradas con responsables de infantes con reticencia vacunal &#40;12 madres y un padre&#41;&#46; Se efectu&#243; un an&#225;lisis tem&#225;tico del contenido&#46; La calidad de los datos se garantiz&#243; mediante estrategias de triangulaci&#243;n&#46;</p></span> <span id="as0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Resultados</span><p id="sp0060" class="elsevierStyleSimplePara elsevierViewall">Entre los elementos que contribuyen a la reticencia vacunal&#44; las participantes destacaron la escasa informaci&#243;n sobre vacunas aportada por el sistema sanitario&#44; la variabilidad en el trato recibido en la consulta y su necesidad de tomar decisiones informadas&#46; La informaci&#243;n insuficiente contribuye a su percepci&#243;n de que el calendario vacunal es excesivo&#44; precoz y r&#237;gido&#44; y a la baja percepci&#243;n del riesgo de algunas enfermedades&#46; Aunque reportan confianza en los servicios sanitarios&#44; muchas lo complementan con servicios privados o no-biom&#233;dicos&#46; Las madres consideraban que la pandemia de COVID-19 hab&#237;a tenido escasa influencia en su reticencia&#46;</p></span> <span id="as0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Conclusiones</span><p id="sp0065" class="elsevierStyleSimplePara elsevierViewall">La reticencia identificada entre las informantes se atribuye a la falta de informaci&#243;n aportada por los servicios sanitarios&#44; a la comunicaci&#243;n y el trato recibido en la consulta y a las dudas no resueltas respecto al calendario vacunal&#46; Se recomienda incrementar las habilidades de los equipos profesionales para mejorar la comunicaci&#243;n con las personas responsables de infantes y aumentar la calidad de la informaci&#243;n que ofrece el Sistema Nacional de Salud&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="np4005">Please cite this article as&#58; Rodr&#237;guez-Pe&#241;a L&#44; Porth&#233; V&#44; Asensio A&#44; Diez &#200;&#46; Reticencia vacunal&#58; opini&#243;n de las personas responsables de los cuidados de infantes en Barcelona&#46; Vacun&#46; 2022&#46; <span class="elsevierStyleInterRef" id="ir3005" href="https://doi.org/10.1016/j.vacun.2022.08.003">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;vacun&#46;2022&#46;08&#46;003</span></p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8239;months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">InCompleteporretraso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MS-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44; 4 and 10&#8239;years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete&#44; with doubts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Online&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8239;years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incomplete due to delay and rejection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#8239;months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete with delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Online&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8239;months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete with delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MS-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8239;years and 9&#8239;months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete with delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MS-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#8239;years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incomplete due to rejection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8239;months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incomplete due to delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8239;years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incompledue to rejection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MS-4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8239;years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Online&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8239;years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complete with delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MU-8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Graduate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8239;months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Incomplete due to delay and rejection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Face to face&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tf1000"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="np2005">The categorisation used in the Barcelona Health Survey &#40;ESB<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> for its initials in Spanish&#41; was followed&#46; Secondary&#58; includes Vocational Training&#46; Graduates&#58; includes PhD&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tf2000"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="np1000">The vaccination schedule has been established at the discretion of the authors&#46; Complete&#58; they have given all the vaccines in the schedule&#46; Incomplete&#58; they have not included all of them&#46; Nil&#58; none of the vaccines have been administered&#44; nor do they plan to do so in the near future&#46; Delayed&#58; according to the time criteria established in the schedule&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Sociodemographic characteristics of participants&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "t0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "al0010"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Health service factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TreatmentThe paediatrician told us&#58; &#8220;I spend time with you because I know you want to vaccinate&#44; but if you don&#39;t&#46;&#46;&#46; I&#39;m leaving&#44; I don&#39;t want to know anything&#33; &#40;HU-1&#41;&#8220;In fact&#44; I have sometimes avoided public health care so as not to feel questioned&#44; so that I wouldn&#39;t be treated badly&#8221; &#40;MU-2&#41;&#46;I think it depends on which professionals you go to when you ask about vaccines&#44; if they see you with doubts&#44; you get very bad treatment &#40;&#46;&#46;&#46;&#41; Maybe you just want information and if they treat you like that you say&#46;&#46;&#46; &#8220;well&#44; forget about the vaccine&#8221; &#40;MU-2&#41;&#46; &#8220;The professionals&#93; generate a bit of stress&#46;&#46;&#46; the baby may be crying&#46;&#46;&#46; and the nurse continues to do things&#46;&#46;&#46; at some point I had to stop and say &#8220;Wait a minute&#44; he&#39;s crying&#33;&#8221; &#40;MU-3&#41;&#8220;I found the paediatrician that I needed for myself&#44; because she didn&#39;t pressure me&#44; she respected my decision&#46;&#46;&#46; and I saw her to be in favour of&#46;&#46;&#46; she wasn&#39;t going to judge or refute what I said&#44; or the decision that I was going to make&#8221; &#40;MS-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Communication&#8220;I feel that &#91;the professionals&#93; sometimes feel uncomfortable when you ask them questions&#8221; &#40;MU-4&#41;&#46;&#8220;The doctor we have explains everything very technically&#44; &#40;&#46;&#46;&#46;&#41; your technical language is not the same as ours&#8221; &#40;MS-1&#41;&#46;&#8220;There is no kind of sensitivity about possible doubts&#46;&#46;&#46; or information about components&#44; side effects&#44; what the point of the vaccine is&#44; why so many doses&#44; why the ages &#40;&#46;&#46;&#46;&#41; It seems to me that there is no space for patient information and decision&#8221; &#40;MS-3&#41;&#46;&#8220;They don&#39;t give me the answer I need&#46;&#46;&#46; I don&#39;t understand it&#44; it is not enough&#44; it is very superficial&#44; they don&#39;t help me&#46;&#46;&#46; so I go to someone who can help me&#8221; &#40;MU-5&#41;&#46;&#8220;I have had to make some visits to private doctors&#46; Because they tell you one thing&#44; but sometimes you don&#39;t quite believe it&#44; and you don&#39;t see another doctor&#46;&#46;&#46; you want another opinion&#8221; &#40;MS-1&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Specific vaccination factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lack of information about vaccines and their characteristics&#8220;My mother-in-law&#93; told me that &#91;vaccines&#93; had a lot of heavy metals&#44; which the liver or the kidney cannot absorb well&#8221; &#40;MS-1&#41;&#46;&#8220;There has been controversy with some that have egg in them that&#44; if you haven&#39;t introduced it in the diet&#44; then they can respond to egg&#46;&#46;&#46; or be allergic or intolerant&#8221; &#40;MU-8&#41;&#8220;Maybe the body is not ready at that time&#46; A month after birth&#46;&#46;&#46; it is a body that still has to be formed&#44; it has to be immunised&#44; it has to become strong&#46;&#46;&#46; and we are injecting it with a virus&#63; What for&#63;&#8221; &#40;MS-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8220;Papilloma&#93; is a relatively new vaccine&#44; there has been talk of side effects&#44; and well&#44; there is a lack of information when a new vaccine comes out when it comes to reassuring parents&#8221; &#40;MS-2&#41;I will certainly vaccinate her &#91;against hepatitis B&#93; because it is something that is not dangerous for my daughter now&#44; but when she gets a few years older it could become dangerous&#8221; &#40;MS-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccination schedulePrecocity&#58; &#8220;I think this is the issue&#44; that he is a baby&#46; It&#39;s not so much that I don&#39;t believe in vaccines&#44; I&#39;ve always been vaccinated&#44; but rather that it&#39;s such a small baby &#40;&#46;&#46;&#46;&#41; he doesn&#39;t even talk&#46; We can&#39;t help him anyway&#33;&#8221; &#40;MU-1&#41;Excess&#58; &#8220;I agree with all the vaccines&#44; but I don&#39;t think it&#39;s necessary to give him 4 vaccines all at once in the months&#44; for reasons of humanity &#91;many jabs&#93; and because it can cause a reaction&#8221; &#40;MS-2&#41;&#46;Rigidity&#58; &#8220;It&#39;s good to study each case&#46;&#46;&#46; each child with their characteristics&#44; life rhythms&#44; medical history&#46;&#46;&#46; To study them in order to adapt their vaccination a bit&#44; instead of making such a generic vaccination for the whole population&#8221; &#40;MU-2&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Individiual and group factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Need for information for decision-making&#8220;We still have a lot of doubts&#46;&#46;&#46; because with other things we have always had a very clear opinion about what we wanted to do&#44; but with this we are finding it very difficult&#8221; &#40;MU-1&#41;&#46;&#8220;With the issue of my children I try to inform myself a lot&#44; because I think that information is power and if you don&#39;t go with your information beforehand&#44; they don&#39;t tell you &#91;the professionals or the care system&#93;&#8221; &#40;MS-2&#41;&#46;&#8220;It is good that we have information so that we can make a decision&#44; to take something based on what you have been able to inform yourself and read&#46; It happens with education too&#44; when you go to look for a school you get information and you look&#44; and if you are going to buy a car too&#46;&#46;&#46; or a house&#46;&#46;&#46;&#8221; &#40;MU-8&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Risk perception&#91;He is making a metaphor between the organism and an operating system&#93; &#8220;It&#39;s like&#44; you instal a lot of things in your device that you will only use 4 of them&#8221; &#40;HU-1&#41; &#91;<span class="elsevierStyleItalic">He is creating a metaphor between the organism and an operating system</span>&#93;&#46;&#8220;A chicken pox or measles that nowadays with the medical innovations that exist&#44; if you catch them&#44; you wouldn&#39;t die&#46; And many people used to die of measles&#8221; &#40;MU-7&#41;&#46;&#8220;I don&#39;t consider chickenpox in particular to be a serious disease&#44; from my own knowledge&#46; Before they didn&#39;t vaccinate and now they do&#8221; &#40;MU-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paradigm of health &#8220;We do look for a bit of an alternative before going for pharmaceutical chemical medication&#46; It is there and it is important to take it when it is necessary&#8221; &#40;MU-8&#41;&#46;&#8220;I relied a lot on my full confidence in the homoeopath who had been monitoring my son since he was one and a half years old&#46; He always told me to do what I wanted&#44; but he believed that some vaccines are more important than others&#8221; &#40;MS-3&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contextual factors&#58; COVID-19 pandemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8220;I think that if the context was not a pandemic I would have made the same decision&#46; Because in the end it is a decision based on a particular way of understanding medicine&#8221; &#40;MU-5&#41;&#46;&#8220;The current context of COVID makes people decide not to vaccinate&#59; I understand that&#44; if you stay at home&#44; there will be many people who will say &#8216;I don&#39;t vaccinate&#8217;&#8220;&#40;MU-1&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Verbatims from participants in keeping with the categories and factors of analysis&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "t0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "al0015"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Receive more information about vaccination&#8220;Hold sessions where they explain what we are vaccinating about&#44; what the vaccines are for&#44; why it is important to follow this schedule and why not&#46;&#46;&#46;&#46; Information that is as objective as possible&#8221; &#40;MU-3&#41;&#8220;I would like them to provide more information about what we are giving our children&#46; What they are for&#44; what they are necessary for&#44; what they help us with and what we prevent&#46; Don&#39;t take everything for granted&#46; To give clear and truthful information&#8221; &#40;MS-2&#41;&#8220;A course like this &#91;with information about vaccinations&#93; can be done easily in the public health system&#44; just like a course on childbirth or breastfeeding&#46; It can even be done before &#91;infants&#93; are born&#44; because pregnant women have a lot of free time&#33;&#8221; &#40;MU-1&#41;Information adapted to the needs of responsible persons&#8220;They should really prepare people according to what they feel&#46; According to their belief&#46; Because beliefs are valid&#46; They are our beliefs and we have to respect them&#46; A doctor should prepare parents to choose what they believe is right for their children&#8221; &#40;MS-4&#41;&#46;Midwives as agents for providing information&#8220;Perhaps it would be good if the one who would transmit this information in a more relaxed way were the midwives&#44; the ones who have controlled your pregnancy and also control your postpartum&#8221; &#40;HU-1&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Suggestions from respondents about improving the approach to reluctance to use health services&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "ec0005"
        "etiqueta" => "Supplementary material"
        "tipo" => "MULTIMEDIAECOMPONENTE"
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        "detalles" => array:1 [
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            "identificador" => "al0020"
            "detalle" => "Supplementary materia"
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        "Ecomponente" => array:2 [
          "fichero" => "mmc1.docx"
          "ficheroTamanyo" => 13570
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bs0005"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bb0005"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ten Great Public Health Achievements at United States &#40;2001&#8211;2010&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Centers for Disease Control&#46; Domestic Public Health Achievements Team"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "WWW" => array:2 [
                        "link" => "https&#58;&#47;&#47;www&#46;cdc&#46;gov&#47;mmwr&#47;preview&#47;mmwrhtml&#47;mm6019a5&#46;htm"
                        "fecha" => "2011"
                      ]
                    ]
                  ]
                ]
              ]
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            1 => array:3 [
              "identificador" => "bb0010"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ten threats to global health in 2019"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "World Health Organisation"
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                  "host" => array:1 [
                    0 => array:1 [
                      "WWW" => array:2 [
                        "link" => "https&#58;&#47;&#47;www&#46;who&#46;int&#47;news-room&#47;spotlight&#47;ten-threats-to-global-health-in-2019"
                        "fecha" => "2020"
                      ]
                    ]
                  ]
                ]
              ]
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Article information

ISSN: 24451460
Original language: English

DOI:10.1016/j.vacune.2023.01.001

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