Journey to vaccination: a protocol for a multinational qualitative study Ana Wheelock, 1 Marisa Miraldo, 2 Anam Parand, 1 Charles Vincent, 3 Nick Sevdalis 1 To cite: Wheelock A, Miraldo M, Parand A, et al. Journey to vaccination: a protocol for a multinational qualitative study. BMJ Open 2014;4:e004279. doi:10.1136/bmjopen-2013- 004279 ▸ Prepublication history for this paper is available online. To view these files please visit the journal online (http://dx.doi.org/10.1136/ bmjopen-2013-004279). Received 17 October 2013 Revised 19 December 2013 Accepted 10 January 2014 1 Faculty of Medicine, Imperial College London, London, UK 2 Imperial College Business School, London, UK 3 Department of Experimental Psychology, University of Oxford, Oxford, UK Correspondence to Ana Wheelock; a.wheelock@imperial.ac.uk ABSTRACT Introduction: In the past two decades, childhood vaccination coverage has increased dramatically, averting an estimated 2–3 million deaths per year. Adult vaccination coverage, however, remains inconsistently recorded and substandard. Although structural barriers are known to limit coverage, social and psychological factors can also affect vaccine uptake. Previous qualitative studies have explored beliefs, attitudes and preferences associated with seasonal influenza (flu) vaccination uptake, yet little research has investigated how participants’ context and experiences influence their vaccination decision-making process over time. This paper aims to provide a detailed account of a mixed methods approach designed to understand the wider constellation of social and psychological factors likely to influence adult vaccination decisions, as well as the context in which these decisions take place, in the USA, the UK, France, India, China and Brazil. Methods and analysis: We employ a combination of qualitative interviewing approaches to reach a comprehensive understanding of the factors influencing vaccination decisions, specifically seasonal flu and tetanus. To elicit these factors, we developed the journey to vaccination, a new qualitative approach anchored on the heuristics and biases tradition and the customer journey mapping approach. A purposive sampling strategy is used to select participants who represent a range of key sociodemographic characteristics. Thematic analysis will be used to analyse the data. Typical journeys to vaccination will be proposed. Ethics and dissemination: Vaccination uptake is significantly influenced by social and psychological factors, some of which are under-reported and poorly understood. This research will provide a deeper understanding of the barriers and drivers to adult vaccination. Our findings will be published in relevant peer-reviewed journals and presented at academic conferences. They will also be presented as practical recommendations at policy and industry meetings and healthcare professionals’ forums. This research was approved by relevant local ethics committees. BACKGROUND In the past two decades, childhood vaccin- ation coverage has increased dramatically, averting an estimated 2–3 million deaths per year, along with myriad episodes of illness and disability. 12 Adult vaccination coverage, however, remains poorly recorded and substandard. 23 Two important adult routine vaccines are seasonal influenza ( flu) and tetanus- containing vaccines. 4 An annual flu vaccine is recommended to all adults, particularly those aged ≥65 years and under 65 years with certain medical conditions such as asthma, heart disease and diabetes. Despite this recommendation, in any given year, flu epidemics can cause between 500 000 and 1 000 000 deaths globally. 5 A tetanus- containing booster is recommended every 10 years to prevent tetanus and other dis- eases such as pertussis, diphtheria and polio. Although tetanus morbidity and mortality is mostly neonatal and maternal, globally, an estimated 13 000 annual non-maternal adults deaths are due to tetanus infection. 6 Moreover, it has been established that unvac- cinated adolescents and adults, or those with waning immunity, have become a major source of pertussis infection for unvaccinated infants. 7 The WHO estimated that, in 2008, 195 000 children under 5 years of age died from pertussis and 199 000 from flu, many of whom were infected by an adult. 8 Although structural barriers, such as access to care and vaccine availability, are known to Strengths and limitations of this study ▪ The journey to vaccination, a multidisciplinary qualitative approach, is used to elicit underlying beliefs, attitudes and preferences affecting vac- cination decisions. ▪ A multinational and relevant sample population will be recruited. ▪ The interview schedules and local interviewers’ training are standardised, which will enable data comparability. ▪ Challenges in recruiting specific participant cat- egories may be encountered and cross-cultural variations will need to be documented and explained. Wheelock A, Miraldo M, Parand A, et al. BMJ Open 2014;4:e004279. doi:10.1136/bmjopen-2013-004279 1 Open Access Protocol group.bmj.com on February 5, 2014 - Published by bmjopen.bmj.com Downloaded from