Family, community, institutional and policy factors on COVID-19 vaccine perceptions among urban poor adolescents in seven countries:  qualitative cross-site analysis.

Purpose: The number of studies examining family, community, institutional and policy factors on COVID-19 vaccine perceptions is limited, with most concentrating on high-income countries and using predominantly quantitative methods. To address this gap, the goal of this manuscript is to qualitatively explore these factors and how they shape adolescents’ perspectives on COVID-19 vaccines across seven countries.   Methods: Focus group discussions (FGDs) were conducted among urban poor adolescent populations (13 - 18 years) across seven countries: Ghent, Belgium; Sao Paulo, Brazil, Shanghai; China, Kinshasa, Democratic Republic of Congo (DRC); Semarang and Denpasar, Indonesia; Blantyre, Malawi and New Orleans, United States of America (USA). An inductive thematic analytical approach was used to understand the emerging themes across the different countries based on the study’s objectives.   Results: The study found that all influences were inter-connected and contributed towards vaccine perceptions among adolescents, which were largely positive except in the two African countries and to an extent in the USA. Family and community influences played a large role in vaccine perceptions, however, this differed by context. Our findings suggest adolescents’ perceptions about vaccines were more positive in countries with higher vaccination rates, i.e. China and Indonesia versus countries with lower vaccination rates i.e. Malawi and DRC. Vaccine mandates within schools, offices, and public places were also discussed with varying perceptions based on government trust.   Conclusion: Adolescents’ perceptions of the Covid-19 vaccine are based on a variety of elements, such as families, community, institutions, and policies. Prioritizing one or another path may not be sufficient to improve vaccine adherence during future pandemics, as we experienced with Covid-19. Strategies to make vaccine perceptions more positive among urban poor adolescents should address both family and community perceptions. However, policies and robust programs around immunization are still needed. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by a gift agreement between AstraZeneca Young Health Programme and Johns Hopkins University. The funder did not play any role in the submission. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study received ethical approval from the University of Ghent in Belgium the University of São Paulo School of Public Health in Brazil Shanghai Institute of Planned Parenthood Research in China Kinshasa School of Public Health in DRC Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada in Indonesia College of Medicine Research Ethics Committee in Malawi and Institute of Women and Ethnic Studies in USA. The study was approved for secondary data analysis in all countries except Kinshasa by the Johns Hopkins Bloomberg School of Public Health’s Institutional Review Board (IRB) (#8549) . In Kinshasa, IRB approval was obtained for primary data collection from the Johns Hopkins Bloomberg School of Public Health (#7510). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data is available as a Supporting File.