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Public health

Protocol

Engaging Canadians in evidence-based communication about vaccines: a scoping
review protocol of immunisation support programs in Canada

1. http://orcid.org/0000-0001-5405-255XKatherine Jennifer Kelly1,
2. http://orcid.org/0000-0001-6461-9054Kim Mears2,
3. Margie Burns3,
4. William Montelpare1

1. 1Department of Applied Human Sciences, University of Prince Edward Island,
Charlottetown, Prince Edward Island, Canada
2. 2Data and Research Services, Robertson Library, University of Prince Edward
Island, Charlottetown, Prince Edward Island, Canada
3. 3Faculty of Nursing, University of Prince Edward Island, Charlottetown,
Prince Edward Island, Canada

1. Correspondence to Dr Katherine Jennifer Kelly; kjkelly@upei.ca

ABSTRACT

Objective To identify, characterise and map the existing knowledge about (1)
immunisation programmes that provide evidence-based support about vaccines to
Canadians and reduce barriers to vaccination; and (2) barriers and facilitators
to the delivery of immunisation support programmes.

Introduction Vaccine hesitancy is a complex issue that has significant
repercussions for the health and safety of Canadians. Engaging in evidence-based
communication about vaccines can reduce vaccine hesitancy and increase
participation in immunisation programmes.

Methods The Joanna Briggs Institute methodology for scoping reviews will be used
for this scoping review. A comprehensive keyword search strategy was developed
and translated for six electronic databases on 19 November 2021: CINAHL via
EBSCOhost, APA PsycINFO via EBSCOhost, Academic Search Complete via EBSCOhost,
Scopus, Medline via EBSCOhost and EmCare via Ovid. We will identify unpublished
literature by searching websites listed in CADTH’s Grey Matters checklist and
other relevant sources in January 2022. Two independent raters will screen and
extract data from identified material. Data will be presented in a tabular form.

Inclusion criteria We will consider Canadian programmes that target the general
public and exclude papers targeting health professionals. Our review will not
limit by vaccine type and will consider any intervention that aims to inform
individuals about immunisation. Our primary concept involves mapping the
characteristics of programmes (eg, programme description, delivery format) and
our secondary concept will examine barriers and facilitators to programme
delivery.

Ethics and dissemination Ethical approval is not required as this study is a
review of the published and publicly reported literature. Findings from this
review will be disseminated to academic and health system stakeholders to inform
immunisation programmes across a wide range of vaccine types and settings. We
intend to use the results of this review to develop an immunisation support
programme in Prince Edward Island, Canada.

* Public health
* COVID-19
* EPIDEMIOLOGY
* Infection control
* Community child health
* PUBLIC HEALTH

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others
to distribute, remix, adapt, build upon this work non-commercially, and license
their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

http://dx.doi.org/10.1136/bmjopen-2021-060103

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* Public health
* COVID-19
* EPIDEMIOLOGY
* Infection control
* Community child health
* PUBLIC HEALTH

STRENGTHS AND LIMITATIONS OF THIS STUDY

* Our team involves individuals with expertise in the area of health services
research and reviews, including researchers, clinicians and a health sciences
librarian.

* Searches in the published and unpublished literature will allow us to
identify programmes informing Canadians about immunisation from a wide range
of sources.

* The article screening and data collection steps will be conducted by two
independent reviewers.

* Despite our attempt to conduct a comprehensive search, we may have missed
interventions that exist in practice and not in the literature or are
published in languages other than English.

INTRODUCTION

Within the range of public health initiatives, immunisation programmes are
arguably among the most important interventions for preventing disease. Vaccines
prevent the untimely death of millions of children and adults around the world.1
The resurgence of once eradicated diseases, such as the measles, demonstrates
the inadvertent impact that vaccine hesitancy and resistance can have on the
health and safety of the public.2 Vaccine hesitancy is conceptualised as the
reluctance to be vaccinated despite the availability of vaccines3 and has been
identified by the WHO as one of the greatest threats to humanity.4 More
recently, hesitation regarding COVID-19 vaccines has led to numerous outbreaks
around the world and in Canada.5

Factors of vaccine hesitancy have been well documented in the literature (for
reviews, see studies by Aw et al,6 Cooper et al,7 Leask et al,8 Hasnan and
Tan6–9). Although vaccine hesitancy can be associated with demographic
characteristics such as age, education and political stance,10 factors of
hesitancy are typically driven by broader influences11 and are largely
context-specific.7 12 Acceptance of vaccines is influenced by a myriad of
factors,3 including mistrust of health authorities13 14; religious beliefs15 16
and misinformation.17 Hesitancy can also be driven by structural barriers,
including financial and other insecurities related to transportation and
childcare.18 Poor communication about immunisation can lead to vaccine hesitancy
and anti-vaccination sentiments.19 Providing evidence-based information about
immunisation, and removing barriers to immunisation, can promote participation
in vaccine programmes.20–23

Acceptance of vaccines range from the vaccine confident to those firmly opposed
to immunisation.8 24 Individuals that fall in the middle of this continuum (eg,
the vaccine hesitant or late/selective vaccinators) are reported as the most
likely to respond to interventions targeting vaccine uptake.8 25 Dissemination
of information about vaccines through immunisation support programmes, such as
knowledge translation programmes that are multicomponent and dialogue-based,26
can help to encourage the acceptance of vaccines among those considered to be
vaccine hesitant.27 Integral to the success of vaccine promotion strategies
include building a rapport with those hesitant or opposed to vaccination and
tailoring the conversation according to factors influencing vaccine
perceptions.7 8 Conversations and information dissemination about immunisation
can occur through various settings (eg, clinics, schools, community centres) to
different sections of the population (eg, urban, rural, indigenous, vulnerable
persons), by diverse teams (eg, nurses, pharmacists, educators).28 29 The goal
of such interventions and communication strategies is typically to promote
uptake of vaccines30 including regular childhood vaccines,31 32 novel,
disease-specific vaccines (eg, influenza33 and COVID-19 vaccines34) and
travel-related vaccines.35

Given the potential impact that communicating evidence-based information about
vaccines can have on participation in immunisation programmes, a review of
existing immunisation support programmes in Canada is warranted. A preliminary
search of CINAHL and Academic Search Complete was conducted and no current or
underway systematic reviews or scoping reviews on the topic were identified.

RESEARCH PURPOSE

The purpose of this scoping review is to identify, characterise and map the
existing knowledge about (1) immunisation programmes that provide evidence-based
support about vaccines to Canadians and reduce barriers to immunisation; and (2)
barriers and facilitators to the delivery of immunisation support programmes.
Findings from this review will inform the development of an immunisation support
programme in Prince Edward Island, Canada. This review represents one phase in a
larger project to reduce vaccine hesitancy and barriers to immunisation, with
the overarching goal to improve vaccine uptake.

RESEARCH QUESTIONS

1. What are the characteristics of immunisation support programmes in Canada
that provide evidence-based information about vaccines, and reduce barriers
to immunisation?

2. What are the perceived barriers and facilitators to information delivery by
immunisation support programmes (including interventions and other
strategies) in Canada?

ELIGIBILITY CRITERIA

PARTICIPANTS

This scoping review will focus on immunisation support programmes that target
various cohorts within the general public, including parents/guardians, infants,
children, adolescents and other adults (eg, school administration, seniors).
Members of the general public will be inclusive of any segment of the population
(eg, indigenous, minority, urban and rural populations); however, we will not
include papers that are limited to the education of health professionals.

CONCEPT

The main concept is the characteristics of immunisation support programmes that
aim to engage the general public to communicate about immunisation and/or
disseminate evidence-based information about vaccines, while reducing barriers
to immunisation. This study defines immunisation support programmes as an
umbrella term for any programme that aims to engage in communication with the
general public about immunisation, using evidence-based information, and/or
reduce structural barriers to immunisation (eg, childcare, transportation). This
includes anything from comprehensive education programmes to reminders and
pamphlet campaign. In this study, we distinguish between immunisation programmes
and immunisation support programmes; the latter is differentiated in this review
by the inclusion of informational, emotional and/or structural or tangible
support to facilitate the decision to become vaccinated (ie, provision of
information or engaging in dialogue beyond what is typically included in a
vaccine consent form). We will not limit papers to any specific vaccine type.
Included papers will discuss the characteristics of Canadian-based immunisation
support programmes, such as setting and delivery format.

The focus of this review is on immunisation support programmes that directly
target members of the general public (eg, parents/guardians) and communicate
evidence-based information about immunisation and/or reduce barriers to
immunisation. The goal of these programmes is to promote the uptake of vaccines
(including, but not limited to: vaccines targeting influenza, COVID-19, human
papillomavirus and routine childhood vaccinations such as measles, mumps and
rubella; pneumococcal conjugate; and tetanus, diphtheria, pertussis). Terms
related to immunisation support programmes (eg, interventions) and terms
synonymous with these programmes (eg, vaccine education) will be used in our
search strategy to cast a wide net across potentially relevant sources.

The secondary concept is barriers and facilitators to the implementation and
delivery of immunisation support programmes in Canada. However, papers do not
need to report on factors related to barriers and/or facilitators to be included
in this review. Papers will be included if they report the main concept:
characteristics of immunisation support programmes. This review will exclude
interventions and communication strategies that do not directly focus on
supporting or communicating with members of the general public about vaccines
(eg, programmes that target health professionals, such as physicians, nurses,
pharmacists, etc).

CONTEXT

This review will consider papers on immunisation support programmes in all
settings, including (but not limited to) clinics (eg, primary care, provincial
public health), community health centres, school settings and research clinics.
We will consider all methods of delivery (eg, phone, videoconferencing,
in-person). Papers will be limited to programmes in Canadian provinces and
territories.

TYPES OF SOURCES

This scoping review will consider both experimental and quasi-experimental study
designs including randomised controlled trials, non-randomised controlled
trials, before and after studies and interrupted time-series studies. In
addition, analytical observational studies including prospective and
retrospective cohort studies, case–control studies and analytical
cross-sectional studies will be considered for inclusion. This review will also
consider descriptive observational study designs including case series,
individual case reports, study protocols and descriptive cross-sectional studies
for inclusion. Qualitative studies will also be considered that focus on
qualitative data including, but not limited to, designs such as phenomenology,
grounded theory, ethnography, qualitative description, action research and
feminist research. Text and opinion papers will also be considered for inclusion
in this scoping review. This review will also consider other literature,
including unpublished papers and evaluation reports. We will exclude all
reviews, such as systematic and scoping reviews, and meta-analyses; however, the
reference list of relevant review papers will be hand searched for additional
studies.

METHODOLOGY

This review will be conducted in accordance with the Joanna Briggs Institute
(JBI) methodology for scoping reviews.36

SEARCH STRATEGY

A three-step search strategy was developed by a research librarian (KM) in
consultation with the research team to identify published empirical articles.
The first step of the search strategy consisted of a limited search of two
databases (CINAHL and Academic Search Complete, both via EBSCOhost) to identify
titles and abstracts of papers that focused on programmes and/or interventions
that provide information about immunisation in Canada. The text words used in
identified articles at this preliminary stage (ie, in titles, abstracts and
keywords) were examined and used to identify additional keywords, subject
headings, descriptors and related search terms. The second stage of the search
strategy involved using the identified keywords to conduct a more comprehensive
search of the literature. The search strategy for a study on the taxonomy of
communication interventions for vaccination was located and adapted37 . The
search strategy, including all identified keywords and index terms, will be
translated for each included database and/or information source. The reference
list of all included sources of evidence will be screened for additional papers.
Only papers published in English will be included due to time and resource
limitations. There will be no cut-off date built into the database searches;
papers from any time period will be considered. Searches for relevant articles
were completed on 19 November 2021 in six electronic databases: CINAHL via
EBSCOhost, APA PsycINFO via EBSCOhost, Academic Search Complete via EBSCOhost,
Scopus, Medline via EBSCOhost and EmCare via Ovid. The syntax for the search
strategy in MEDLINE via EBSCOhost is outlined in online supplemental file 1. A
detailed search process that follows the Preferred Reporting Items for
Systematic reviews and Meta-Analyses literature search extension (PRISMA-S) will
also be included in the scoping review.38

SUPPLEMENTAL MATERIAL

[bmjopen-2021-060103supp001.pdf]

The third step of the search strategy included a search for scientific evidence
published in sources other than journals, such as publications from other
sources and evidence-based consensus expert opinion papers. This search will
consist of a broad search on the first 10 pages of Google Scholar. We will also
search for literature using the Canadian Agency for Drugs and Technologies in
Health Grey Matters checklist.39 Relevant organisational, governmental and
healthcare association websites will also be reviewed, including the Public
Health Agency of Canada, the Government of Canada (eg, National Advisory
Committee on Immunization statements and publications), Immunize Canada,
Indigenous Services Canada and Infection Prevention and Control Canada. We will
identify additional sources by inquiring with relevant stakeholders through
provincial Chief Public Health Office and regional health authorities. A full
list of databases used to search the unpublished literature and corresponding
keyword searches will be made available in the final review.

STUDY SELECTION

Papers identified in the keyword searches will undergo a careful process of
selection to be included in the final scoping review. Citations identified by
the keyword searches will be exported from their respective databases and
collated in Covidence, an online review management platform that facilitates
article screening and data extraction,40 where duplicates will be removed.

The selection of papers will begin with a screening of titles and abstracts,
followed by a more in-depth screening of full-text papers. Two independent
reviewers (KJK and JL) will conduct the first level of title and abstract
screening against the established eligibility criteria. A calibration test on 50
titles and abstracts will be conducted to evaluate reviewer agreement in the
screening process. The resulting kappa statistic (ie, measure of inter-rater
agreement) will be assessed to determine whether agreement is sufficient for
further independent screening.41 If agreement is not sufficient (eg, the
statistic is 0.60 or less, indicating fair or no agreement41), the reviewers
will find a consensus on conflicting articles and independently screen an
additional 50 articles. Reviewers will meet to discuss any discrepancies, and a
third reviewer (WM) will resolve any outstanding conflicts.

Potentially relevant sources will be retrieved in full and their citation
details will be imported into Covidence. The same two reviewers (KJK and JL)
will independently screen full-text papers against the inclusion criteria using
the same process as the one described above. Reasons for exclusion of sources of
evidence at full text that do not meet the inclusion criteria will be recorded
and reported in the final review. Any disagreements that arise between the
reviewers at each stage of the selection process will be resolved through
discussion or with an additional reviewer (WM). The results of the search and
the study inclusion process will be reported in full in the final scoping review
and presented in a Preferred Reporting Items for Systematic Reviews and
Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram.42

DATA EXTRACTION

Data will be extracted from papers by two independent reviewers using a data
extraction tool developed by the research team and implemented in Covidence (see
online supplemental file 2). Information that will be extracted from papers will
include: (1) characteristics of the article, including: author(s); year of
publication; publication journal; study design; study objectives (including
aims/purpose); research question(s); methodology (including philosophical
perspective); and (2) characteristics of the programme/intervention, including:
programme name; programme description; target population and participant
details; delivery format; programme delivery personnel and team format; setting
(eg, community, clinical); context; geographical location; vaccine type(s); data
analysis; outcome measures; reported barriers/facilitators to intervention
implementation and/or delivery; author’s conclusion (ie, key findings);
implications; identified gaps/future directions; reviewer’s comments.

SUPPLEMENTAL MATERIAL

[bmjopen-2021-060103supp002.pdf]

The draft data extraction tool will be modified and revised as necessary during
the process of extracting data from each included evidence source. Modifications
will be detailed in the scoping review. Any disagreements that arise between the
reviewers will be resolved through discussion or with an additional reviewer
(WM). If appropriate, authors of papers will be contacted to request missing or
additional data, where required.

DATA ANALYSIS AND PRESENTATION

The results of the search will be synthesised, summarised and reported in full
in the final scoping review and presented in a PRISMA-ScR flow diagram.42 All
extracted data will be combined to provide one complete dataset for analysis and
cleaned by one reviewer. The extracted data will be presented in a tabular form
that aligns with the study’s objectives. Specifically, one table will include
author(s); year of publication; publication journal; study design; study
objectives (including aims/purpose); research question(s); and methodology
(including philosophical perspective); target population and participant
details; delivery format; setting (eg, community, clinical); context;
geographical location; vaccine type(s); data analysis; outcome measures;
implications; identified limitations. A second table will include programme
name; programme description; programme delivery personnel and team format; and
reported barriers/facilitators to intervention implementation and/or delivery.
We will also present a narrative summary and discussion of the table, describing
how the results relate to the review objectives and questions.

STRENGTHS AND LIMITATIONS

We will follow established scoping review methods described by the JBI and
report the review using the PRISMA-ScR checklist. Two independent reviewers will
evaluate papers at the level of study selection and data extraction to minimise
the risk of errors. We aim to be comprehensive in our consideration of
literature from peer-reviewed sources in multiple health and education-related
databases; however, limitations regarding the restriction to English-language
papers may lead to the exclusion of relevant papers in other languages. For
example, it is likely that immunisation support programmes based in Quebec will
be omitted from the current review, thus impacting the generalisability of
findings. Moreover, despite a careful and iterative process of keyword
selection, our strategy may not lead to the identification of all papers that
describe immunisation support programmes in Canada.

PATIENT AND PUBLIC INVOLVEMENT

No patients or public were involved in the study.

ETHICS AND DISSEMINATION

Ethical approval is not required as this study is a review of the published and
publicly reported literature. The goal of this scoping review is to characterise
and map existing immunisation promotion programmes in Canada. We intend to use
the results of this scoping review to develop a province-wide immunisation
support programme in Prince Edward Island, Canada. Specifically, our programme
aims to promote knowledge translation about immunisation, and especially the
COVID-19 vaccine, and to increase health literacy. Through a partnership with
CHANCES, a charitable organisation that provides programming and support to PEI
children and their families,43 we aim to provide informational, emotional and
structural (ie, through the reduction of barriers such as child care,
transportation) support to Islanders relative to COVID-19 immunisation. Findings
from this scoping review will inform the framework of our programme using
lessons learnt and best practices from similar programmes. Findings from this
review may also inform other immunisation programmes across a wide range of
vaccine types and settings. We will share the findings with key academic and
health system stakeholders through brief evidence summaries, knowledge
translation reports, informal presentations and conference meetings.

ETHICS STATEMENTS

PATIENT CONSENT FOR PUBLICATION

Not applicable.

ACKNOWLEDGMENTS

We would like to acknowledge the contribution of Dr Janet Loo as the duplicate
screener (ie, inter-rater evaluator) in this scoping review.

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SUPPLEMENTARY MATERIALS

* SUPPLEMENTARY DATA

This web only file has been produced by the BMJ Publishing Group from an
electronic file supplied by the author(s) and has not been edited for
content.

* Data supplement 1
* Data supplement 2

FOOTNOTES

* Contributors KJK substantially contributed to the conception and design of
this project (eg, expert contribution to the process of conducting a scoping
review); primary author of the completed manuscript; critically revised the
important intellectual content and gave final approval for the version to be
submitted for consideration. KM substantially contributed to the conception
and design of this project (ie, expert librarian who developed the keyword
search strategy and conducted the retrieval of papers); critically revised
the important intellectual content; and gave final approval for the version
to be submitted for consideration. MB and WM substantially contributed to the
conception and design of this project, and drafting/interpretation of data
for the work; critically revised the important intellectual content and gave
final approval for the version to be submitted for consideration.

* Funding This work is supported by the Public Health Agency of Canada, through
the Immunisation Partnership Fund.

* Competing interests None declared.

* Patient and public involvement Patients and/or the public were not involved
in the design, or conduct, or reporting, or dissemination plans of this
research.

* Provenance and peer review Not commissioned; externally peer reviewed.

* Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-reviewed. Any opinions or recommendations discussed are solely those of
the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the
content includes any translated material, BMJ does not warrant the accuracy
and reliability of the translations (including but not limited to local
regulations, clinical guidelines, terminology, drug names and drug dosages),
and is not responsible for any error and/or omissions arising from
translation and adaptation or otherwise.

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