Older people are confronted with a myriad of challenges throughout the course of their lives in the present society. One of these is the issue of suicidal behaviour among people of older age. This article understands the nature and examines the cause of mortality due to suicide among older people in later life. The author has applied the document analysis method. The information for the current research has been collected using the news content of various Indian newspapers, magazines, and news portals. The researcher was collated 60 occurrences of old-age suicide from the newspapers of Northern Indian states from March 2022 to June 2022. The study has indicated that there is a substantial rise in old-age suicide due to the vulnerable condition of older people in late life. Moreover, the vulnerable condition of older people has led to various factors instrumental in old-age suicide, such as abuse in the family, chronic diseases, depression, poverty, and social rejection that give rise to feelings of committing suicide among the older people. The population of older people in the world has grown steadily during the last years of the last century. The number of people aged 60 years and over in the world was 673 million in the early years of the 21st century and is expected to increase to 2 billion by 2050 . Nearly,The death of older people caused by suicide is a matter of grave concern across all Indian states in contemporary times. At present, a number of older people in Indian society are taking their own lives because of their vulnerable conditions in later life. Suicide among older people has not been a problem in India because of its congenial social environment and value-based family structure. However, it has been pointed out that the roots of a congenial social environment and value-based family structure are eroding very fast due to changing socio-economic scenarios, such as industrialisation, urbanisation, and globalisation . The rapAs the proportion of older people in the population will increase all over the world in the coming decades, the cases of suicide among older people are also expected to be on the rise consequently . World HIn the last few years, the problem of suicide among older people has attracted social scientists from different regions of the country. Many studies  related Vulnerability states the diminished capacity of an individual who feels that he does not have a strong social and physical ability to protect himself from any problem  . There aThe researcher has used the document analysis method, which is basically a kind of content analysis, for the study of suicide among older people in India. The aim of the document analysis was to investigate and analyse any issue that is printed and electronic documents in the form of books, newspaper articles, and magazines . “DocumeThe data on old-age suicide have been obtained from Northern states of India, such as Bihar, Delhi, Haryana, Madhya Pradesh, Maharashtra, Rajasthan, Uttar Pradesh, and Uttarakhand. In view of the fact that instances of suicide committed by older people are often reported and highlighted by newspapers and other news portals in these states. This study’s sample cases were acquired manually by reading every suicide-related news article published in newspapers. The researcher discovered typical keywords used by Indian journalists while reporting on a certain topic in newspapers and utilised those keywords to search for information on Internet platforms. The terms such as suicide, suicidal propensity, self-harm, self-killing, chronic illnesses, depression, mental health, and frustration, among others are utilised while doing a web search for information about suicide in India.Therefore, the researcher has decided to conduct a study on old-age suicide in these states. The author collected around 100 newspaper articles on old-age issues using document analysis. From these 100 news articles, the author chose 60 news articles related to old-age suicide. This study’s sample cases were acquired manually by reading every suicide-related news article published in newspapers. The majority of the 60 reported cases of old-age suicide were found in these regions from the age group of 60 years to above 80 years. Each of these incidents of elder suicide has been divided into several themes, such as gender , causes of suicide among older people , and nature of suicide . Thus, the researcher has gathered data on old-age suicide from both print and electronic media, and the author has used document analysis to describe the nature and causes of old-age suicide in India.The problem of suicide is very sensitive in India and people associate suicide with stigma. For this reason, the family members of the affected person do not openly talk about the cause of committing suicide. Due to this, a researcher has to face many difficulties in conducting a primary survey on suicide. Apart from this, the data on suicide collected by the National Crime Record Bureau in India do not show rural–urban differences in suicide in its report. Moreover, N.C.R.B. does not separately publish the causes of old-age suicides in its suicide data, which does not make the understanding of the nature of suicide among older people. For this reason, when a researcher wants to study suicide focused on older people, he does not get the data related to rural–urban differences, causes, and nature of suicide among older people. However, when a researcher collects data on suicide through newspapers, he gets the data easily whatever he wants to examine. Consequently, this method of data collection is chosen as the most suitable for gathering data on old-age suicide within the stipulated time frame. The incidents of old-age suicide have been meticulously collated from news items published in different Indian newspapers and news portals. Using observation, scientific view, and fact examination, the researcher has analysed each instance from two or three newspapers and other sources . This haThis study  has founPersonal anomie refers to a condition in which personal problems arise before an individual in society due to the effect of rapid social change and unwanted phenomena. When the person is unable to overcome the problems arising due to these side effects, he is compelled to commit suicide. This study examines the nature of suicide among older people as motivated by personal causes. The researcher has pointed out in his study that personal problems were the underlying cause of suicide in 50.00% of cases. The researcher has found through analysis of news content that older people who had a personal nature of suicide were more likely to suffer from problems, such as chronic disease (28.33%) and depression (21.67%).For example, based on news content, we may observe two significant suicide occurrences in which an old person took his or her own life due to chronic disease and depression.Familial problems may be defined as any kind of dysfunction within a family due to rapid change and irrelevant incidents. In such a situation, a person does not live up to his or her family’s expectations, and his or her family situation becomes unstable. When the person does not see a way out of the family problems, he is forced to commit suicide. The researcher has found in his study that in approximately 35.00% of older people, the nature of suicide was due to familial problems. The study has found that older people who committed suicide were abused (18.33%) by family members and they lived in poverty (16.67%). For instance, based on news content, we may identify two prominent suicide occurrences in which an old person committed suicide as a result of abuse in family and poverty.Social problems are a condition of society in which due to rapid social change and irrelevant phenomena, social norms and values weaken and give rise to many problems. These problems promote a state of deviance affecting the whole society directly and indirectly. In such a situation, when the particular person who is suffering from it is unable to get out of these problems, he is forced to commit suicide. The researcher has found in the study that in the changing socio-economic scenario, approximately 15.00% of the total suicides of older people were committed due to social problems. When the researcher studied suicide among older people based on social problems, it was found that those who committed suicide were more likely to suffer from social rejection (15.00%). For example, we can discuss a case of suicide in which an old person committed suicide due to social rejection in the neighbourhood.There is strong agreement that old age is a time of increasing vulnerability . It is tRapid socio-economic changes in the era of industrialisation, urbanisation, and globalisation have had positive and negative impacts on human beings and society. On the one hand, the positive impact has given a better life in society. On the other hand, the negative impact has weakened interpersonal relationships among family members. The weakened interpersonal relationships due to these socio-economic changes have made a vulnerable condition for older people in the family. The increasing incidents of suicide among older people are the result of this vulnerable condition. At present, all the suicides among older people happening in Indian society are directly or indirectly due to vulnerability in later life. This study has found that older people committed suicide due to social vulnerability and physical vulnerability. Moreover, during the COVID-19 pandemic, people avoided older people in the family and society because they were afraid of fear of contracting the coronavirus . This maThis study is based on a content study of a few Hindi and English language Indian newspapers. Only a few states of India are included in the study’s sample regions, such as Bihar, Delhi, Haryana, Madhya Pradesh, Maharashtra, Rajasthan, Uttar Pradesh, and Uttarakhand. The chosen sample region does not provide a full picture of suicide among older people in India. The study suggests that suicide among older people is an alarming societal problem in contemporary times that may have been caused by a number of factors, such as social vulnerability  and physical vulnerability (chronic disease and depression) of older people in later life, which led to low belongingness and perceived burdensomeness. According to the data collected from March 2022 to June 2022, older men (56.67%) committed the majority of suicides. In addition, the study indicates that respect, honour, prestige, and authority held by older people in traditional Indian society have begun to decline progressively. In a society undergoing such rapid changes, older people are subject to social-psychological issues, such as loneliness, alienation, helplessness, and despair. All these social-psychological problems have a negative impact on the wellbeing of older people that contributes to the rising suicidal tendency among older people.Finally, it is of the utmost significance to comprehend that our parents and other senior people are analogous to trees; they play a role in our courtyard, similar to that of providing shade and protection. They also provide us with the benefit of their knowledge and blessings due to that we go ahead smoothly in the journey of life. We owe a debt of gratitude to our elders who have shaped our personality, architected our vision of life, and taught us the ability to keep working after they have passed away. It should be not only our emotional responsibility but also our moral responsibility to provide a friendly environment for our parents and other older people at the end of their lives so that they can fully enjoy their lives without any problem.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The author confirms being the sole contributor of this work and has approved it for publication.


Marshall McLuhan once proposed the concept of “global village,” believing that with the help of electronic media, Earth has become indistinguishable from a community, and there is only one Earth for human beings and one world for all countries. Today, with the continuous development of media technology, the concept of a human destiny community has also gained the general consensus of people around the world. The global value of the human destiny community encompasses the interdependent concept of international power, the concept of common interests, the concept of sustainable development, and the concept of global governance. In particular, the concepts of sustainable development and global governance have been advocated by the public, which in turn has led to extensive public discussions on Socioscientific Issues (SSI), in which the teaching of SSI is gradually considered by the international science education community as one of the important goals of science education. The current issues and challenges facing SSI teaching and how immersive media technologies can facilitate SSI teaching have become important issues of keen public interest. Socioscientific issues (SSI) stems from a reflection on the role of science and technology as a double-edged sword that brings positive utility on the one hand and adverse effects on the other in its application. Therefore, the application of science and technology is always associated with moral and ethical issues, and science and technology also bring about ecological and environmental problems, global governance, etc. These problems are increasingly affecting the survival of human beings, and people will think ethically and morally about the application of science and technology. In the process of thinking, controversial issues are generated, which is the source of SSI . SSI is A large number of existing studies have examined SSI-based learning can enhance students’ disciplinary knowledge and scientific literacy. These articles emphasized interdisciplinarity approach in socio-scientific issues in terms of specific issues. Despite the focus on school lessons, some researchers notes the comprehensive abilities for being an outstanding citizen when dealing with socio-scientific issues. These abilities involved many aspects, such as Critical Thinking (CT), Rumor discrimination ability, and other higher-order cognitive thinking skill for making decisions. For instance, Some researches revealed relevant individual attitudes toward SSIs. Numerous scholars have conducted extensive research in diverse teaching methods used in SSI-based Education. There are also a small number of studies have involved immersive media technology in SSI education. Overall, there has been very little discussion about SSIs in an Immersive Media Technology Context. On the one hand, the existing studies are predominantly focused on a single topic of SSIs, and lacked a systematic classification of these topics. On the other hand, the role of Immersive Media technologies and its effects in SSIs teaching were not discussed in-depth. This manuscript establishes an evaluation system for SSIs education, systematically and quantitatively examines the factors that influence SSIs education, and discusses the role of Immersive Media in public understanding of SSI in a bid to address the gap.Back in the 1920s, when radio technology was first invented, McLuhan used the term “global village” to describe the great impact of radio technology on human society. McLuhan used the term “global village” as such, “But one thing is for sure: the discovery of electromagnetic waves has reshaped the synchronous ‘field’ of all human things, so that the human family exists in the ‘global village’ state” , or someFor many centuries, the struggle for international power among different countries and groups has been dominated by wars, which have brought untold disasters to mankind and caused many tragedies in human history. Today, with the increasingly frequent transnational movement of science and technology, capital, population and other elements, the world is tightly linked into a whole. A bond of interest is formed between countries in order to realize their respective interests. Therefore, a country that wants to assert its international power and thus achieve its interests does not necessarily have to go to war, as it did before. The economic interdependence between countries has contributed to the slowing down of the international situation. During the formation of the international system, the contrast between the level of science and technology between countries can be used as a measure of the international position occupied by a country. Therefore, all countries hope to enhance their economic strength and international status through innovative research in basic science and the application of new technologies, so as to take their place in the international system. It is for this reason that the moral and ethical issues of countries in applying science and technology to gain international status have been raised, and these issues have become a hot topic of public concern, which has given rise to SSI on the international concept of power. The common topics of SSI on the international view of power and its manifestations include the following: (1) Discussion of “hegemonism” in science and technology. Scientific and technological “hegemonism” manifests itself in the form of international suppression, bullying, and isolation of countries with a later start, a weaker foundation, and a lower level of science and technology by some countries that have started the scientific and technological revolution earlier and are therefore stronger in science and technology. It also manifests itself in unilateral protectionism in science and technology, imposing sanctions on technology companies of other countries. (2) Discussion of nuclear war. The emergence of nuclear weapons is a great progress in the history of human science and technology, but at the same time, it will also cause a crisis of human’s own survival. Once a nuclear war breaks out, mankind will face an unprecedented disaster. The famous scientist Albert Einstein once said candidly that mankind should destroy nuclear weapons to avoid possible nuclear war. Currently, however, mankind obviously has no intention of destroying nuclear weapons, which has to arouse people’s concern and discussion on this issue. (3) The discussion of artificial intelligence technology. AI technology is the frontier and focus of world science and technology competition at present and in the near future, so it is also a hot area of science and technology innovation in various countries. However, will AI benefit mankind? Stephen Hawking has questioned it, and he warned that people should be wary of AI. The discussion of AI technology also appears in people’s daily lives.The view of national interest has different connotations in different times. During the monarchy period, the interests of the state represented only the interests of the monarch and the royal aristocracy in the country. In the 20th century, the interests of the international community were described as a zero-sum relationship with an exclusive nature. Under the conditions of economic globalization, the concept of national interests has been defined in a new way. First of all, there is a deeper reflection on the traditional view of national interests. Today, as the world is increasingly integrated into a “global village,” one country may serve its own interests and realize its own interests to the detriment of others, because the interests of all countries have become highly intertwined and formed a chain of interests that binds all countries together. Globalization has broken the limitation of time and space, which makes the people of the world more and more closely connected to each other and their interests more and more intertwined. However, conflicts of interests and disputes among countries still exist, and the phenomenon of unreasonable and unjust distribution of international interests still exists . In thisThe Rio Declaration on Environment and Development,” “The Johannesburg Plan of Implementation,” and “The Future We Want” and other achievement documents with the core concept of sustainable development have emerged. The concept of sustainable development is increasingly becoming a consensus issue for countries around the world to consider when formulating their development plans. Led by the value of sustainable development, SSI focuses on reflecting on the environmental problems brought by science and technology to human beings. At present, the environmental problems plaguing human beings include global warming, the sharp decline of biodiversity, the deterioration of air quality, and the shortage and deterioration of water resources, etc. The SSI on sustainable development is also centered on these issues. (1) Discussion of global warming. Although the international community has made a collective effort, and the “Paris Agreement” established in 2015 set the goal of keeping global warming within 2°C of pre-industrial levels for nearly a century and striving to achieve the target of 1.5°C  published on the 50th anniversary of the United Nations. The core concept of global governance is that, in the context of the era of global integration, the international action subjects are diversified. The subjects to deal with global issues also consist of different governments, intergovernmental organizations, non-governmental organizations, multinational corporations, etc. It is only through the interaction of these pluralistic subjects in joint participation and mutual consultation that the current global issues can be solved in a good and practical way. The global governance issues facing human society are diverse, ranging from development issues, security issues, to environmental and other multifaceted issues. How to formulate a reasonable global governance norm in the global context and make it universally mechanism and morally binding to the global governance subjects has become the key to properly deal with these global issues. Throughout the context of global integration, various global problems caused by science and technology are not well solved because of the absence of such a well-regulated global governance system. Therefore, the SSI on the concept of global governance revolves around these issues. (1) Discussion of the ethical norms of biotechnology. Biotechnology is also a globally developed technology field, and biotechnology without appropriate ethical norms to restrict its use may lead to global biosafety issues and moral and ethical problems. The development of cloning technology, for example, has led people to think about the ethical issues involved. In particular, nowadays the emergence of cloning technologies such as gene cloning has forced people to be wary of such biotechnology. Another example is the question of whether genetically modified foods are harmful to human health, which makes people fearful when they talk about genetic modification. Furthermore, the problem of microbial leakage caused by experiments on viruses and other microorganisms has a direct impact on the survival of human beings. (2) Discussions by regional organizations. An international organization formed by some countries to promote the unity and solidarity of the region to which they belong and to strengthen mutual cooperation in politics, economics, diplomacy, defense and security. For example, the European Union, BRICs, G8 Group, etc. The issue of how to achieve benefit sharing has been widely discussed.The scientific concept of global governance was introduced in the report “In order to establish an assessment system for SSI education and to systematically and quantitatively examine the influence of various factors on SSI education, this study uses a hierarchical structure model for specific model construction. The model consists of two primary criteria, four secondary criteria and 15 tertiary criteria, which are expressed as shown in In the multi-level structure model, the importance of each indicator is bound to vary, and it is necessary to quantitatively describe the same level elements by comparing them two by two through the 9-level scale method, construct a judgment matrix, and calculate the weights occupied by each criterion to assist in decision analysis.To enhance the rationality and refinement of the model, this study was based on the Delphi method, and the importance of the above factors was judged by distributing questionnaires to 20 experts. The expert group selected for this study was composed of teachers from several universities and Ph.D. students with education-related backgrounds with remarkable representativeness, all with higher education and certain teaching experience, to ensure the authenticity, scientific validity, and accuracy of the feedback data. In order to eliminate interference, the experts evaluated the questionnaires based solely on their personal perceptions during the process of distribution, without meeting, communicating or interfering with each other.Hierarchical analysis was first proposed in the 1970s by American operations researcher T. L. Saaty, a professor at the University of Pittsburgh, as a method of analysis for multiple indicator problems . It operBased on Thomas Satie’s literature, this study used a 5-level scale approach, in which experts were asked to subjectively assign weights to the indicators in the model. The hierarchical analysis method is divided into five scales: equally important, slightly important, quite important, extremely important, and absolutely important, with the values 1, 3, 5, 7, and 9, in addition to four scales between these five scales, namely 2, 4, 6, and 8. The assessment scales and their interpretations are shown in i, αj  denote factors. αij denotes the relative importance value of αi to αj, satisfying αij > 0 and αij = 1/αij, and the judgment matrix is expressed as follows:The judgment matrix Q is obtained after pairwise comparison of each indicator at the same level of hierarchy as follows. In Q, αmax − n)/(n − 1).In order to avoid contradictions in the logic brought about by subjective decisions during pairwise comparison of the criteria of each level of SSI education by the relevant experts, a consistency test is needed to detect the reasonableness of the judgments made by the expert questionnaire. The test method is as follows: CR = CI/RI, where CI = (λmax denotes the maximum eigenvalue of the matrix, and RI is the random consistency index, whose values are shown in In the above equation, CR is the consistency ratio, CI is the consistency index, λAccording to Satie’s suggestion, when CR < 0.1, the degree of consistency of the judgment matrix is more desirable; otherwise, the values of indicators in each layer need to be readjusted. In the judgment matrix of this study, all the CR values are less than 0.1, so the expert decision data pass the consistency test. After calculation, the weight data in Immersive media refers to the use of computer generated technologies such as VR, AR that isolate the users from the real world while presenting reality as a three-dimensional virtual environment . The funIn today’s rapid development of information technology, the Internet has entered thousands of households. Especially, the popularity of cell phones has increased people’s access to the Internet and reduced the cost. According to the data, the Internet penetration rate in China has reached 94.6% by 2019. Thus, it becomes possible to implement SSI teaching online. When we compare the offline viewing SSI teaching with the online immersion SSI teaching, we know that the online immersion SSI teaching has more weight. This is because online immersive SSI teaching is not only convenient, but also maximizes the characteristics and advantages of immersive media technologies that are not limited by time and space. Although there are many weaknesses in the current online teaching resource platforms, such as the lack of sharing among different teaching resource platforms, slow updating of teaching resources, and teachers’ inability to understand students’ online learning, etc. . HoweverThe development of immersive media technology has broken the limitations of traditional SSI teaching methods. Traditional SSI teaching methods are limited to book teaching, oral teaching, electronic audio-visual teaching, etc. These traditional SSI teaching methods are increasingly inadequate to meet the demands of SSI teaching in the context of globalization and the increasing global issues today. People are no longer satisfied with the traditional means of accessing SSI resources through reading books, especially for children who are full of the unknown and eager to learn about the world. Traditional SSI teaching methods are not only limited in satisfying children’s curiosity, but also not motivating children to think actively. Immersive media technology certainly provides a new opportunity to revolutionize SSI teaching and learning. Immersive media technologies can provide high quality, intuitive and multi-sensory stimulating SSI situations to the educated population. Multi-functional immersive SSI teaching and learning experience centers with low entry barriers can be established in various places, and science teachers can regularly lead children to visit, experience and learn in the experience centers, so that they can realistically and genuinely feel the multifaceted problems brought by technology to human beings and drive them to think actively. In the comparison of the secondary guidelines, the view of sustainable development has the greatest weight, because environmental protection and sustainable development are becoming major issues of concern. The global warming issue, the deterioration of water resources, and the carbon neutrality issue, which are related to the view of sustainable development, are all given considerable weight in the three-level guidelines we developed. The peer weights they occupied are 0.3452, 0.3296, and 0.3252, respectively. Therefore, we can conduct immersive SSI teaching for these issues of sustainable development. For example, we can use immersive media technology to build an experience hall that can virtually simulate the ecological and environmental crises of the Earth, and in the process of teaching biology courses, we can lead students to visit this experience hall to make them feel the ecological and environmental crises that Earth is suffering from. This will lead them to think about the science nature and establish a correct view of the science nature. In addition, although the weight of nuclear weapons in the tertiary guidelines is not significant, we are always facing the threat of nuclear war and nuclear leakage. With the development of immersive media technology, we can even establish experience museums to simulate nuclear war and nuclear leakage and other situations, which also become the future of immersive SSI instruction.Compared to traditional SSI teaching, there is a certain threshold of technical proficiency in using immersive media technologies for SSI teaching. For most science teachers, the ability to use and manipulate immersive media technology to build highly feasible SSI instructional contexts is limited by the science teachers’ proficiency with this technology. Therefore, training science teachers on immersive media technology becomes critical to the success and effectiveness of immersive media technology in facilitating SSI teaching. In addition, training science teachers in immersive media technology should be accompanied by training them in SSI teaching, and this is an even more important aspect. First, training should be conducted to strengthen science teachers’ understanding of SSI content knowledge. Research studies by Liu Enshan’s team as well as by Under the leadership of the value of human destiny community, SSI teaching must focus on global issues, including development issues, governance issues, political and economic conflicts, sustainable development issues, and other issues faced by human beings. This has become an irreversible trend in SSI teaching. In the secondary guidelines, the peer weights of international power perspective, common interest perspective, sustainable development perspective and global governance perspective are 0.2281, 0.2514, 0.2754, and 0.2451, respectively. To carry out immersive SSI teaching accordingly, scientific and reasonable teaching plans and contents should be formulated according to the different weights. In the process of continuously promoting the integration of immersive media technology and SSI teaching, more attention should be paid to the characteristics and advantages of immersive media technology, i.e., the ability to build SSI teaching contexts by constructing virtual scenarios. For example, in SSI teaching about sustainable development, the use of immersive media technology to build virtual scenarios of environmental deterioration not only allows students to intuitively experience the environmental problems in their own countries, but also allows them to see the impact of the environmental deterioration problems brought by technology to Earth on the oceans, glaciers, climate, and various other aspects. This is beneficial for students to expand their perspective and understand the nature of science. The question of how immersive media technologies can be integrated into SSI teaching, and how to focus on global issues in this integration, is a critical topic for research.This manuscript has explored the multidimensional perspectives provided by the international power perspective, common interest perspective, sustainable development perspective, and global governance perspective on SSI under the value of human destiny community. At the same time, an assessment system of SSI teaching is constructed in order to quantitatively examine the impact of each factor on SSI teaching. By collecting experts’ opinions through Delphi method to measure the indicators of the model, we found that it is more critical to choose a type of SSI teaching method to enhance the effectiveness of SSI teaching than the choice of SSI teaching content. In the context of accelerated globalization, there are a variety of issues raised by science and technology, and there are also a variety of SSIs generated. SSI teaching methods must keep pace with them, which requires us to continuously improve teaching methods and adopt different teaching methods for different SSIs. Immersive SSI teaching is better than traditional debate-based SSI teaching both in terms of weighting and teaching effectiveness. Therefore, this manuscript proposes four feasible suggestions on how to achieve the integration of immersive media technology and SSI teaching. Combined with the results of the model, this manuscript suggests that we should actively explore the application of immersive media technology in SSI on international power, common interests, and global governance, and build practical SSI teaching contexts. The corresponding SSI teaching methods can be based on offline discussion-based teaching and online immersion-based teaching. For SSI teaching on sustainability, the use of immersive media technology will be more widespread. We can establish a multi-functional immersive media technology experience hall and build a variety of virtual situations for SSI teaching, so that students can personally feel the changes that are taking place in the global environment. Thus students can actively reflect on the global warming problem and find ways to solve it, and they can therefore care for and protect nature more. In addition, it is worth mentioning that regional organizations in the global governance perspective are also attracting more attention. This is because in the context of the accelerated evolution of globalization, a variety of regional organizations are increasingly influencing people’s lives and have become an indispensable part of global governance. Therefore, teaching in this area should be appropriately increased in the content of immersive SSI. The application of immersive media technology in SSI teaching is still very promising, and how to apply it to SSI teaching and its effect is still a new problem for us. This manuscript tries to provide theoretical guidance on how to achieve the integration of immersive media technology and SSI teaching in the context of globalization.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JZ: conceptualization, methodology, and software. ZK: data curation, writing – original draft preparation. SZ: visualization and investigation. FZ: software and validation. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases. Snakebite envenoming (SBE) is considered a neglected tropical disease and public health problem that is more prevalent in underdeveloped, tropical countries, and about 2.5 million envenomings and at least 100,000 deaths occur each year .In 2018, the World Health Organization (WHO) launched a strategy to reduce mortality and disability caused by SBE by half by 2030. This strategy will include ensuring safe, accessible and effective treatment; empowering communities to be proactive in preventing bites; improving access to treatment; and strengthening local health systems to achieve better outcomes for patients .For the management of SBEs, antivenom is the only treatment with proven efficacy ,2. Thus,In order to ensure adequate and quality care, it is therefore critical, while improving access to antivenom, to simultaneously create and validate antivenom administration protocols. The training of medical personnel and the development of standard treatment protocols are thus priorities for adequate SBE management. As such, the present study aims to develop a clinical practice guideline (CPG) that guides health professionals in the use of antivenom and SBE management in Brazil. In addition to current antivenom care guidelines, we assembled practical ancillary treatment solutions including first aid, wound care and pain management.The study follows a mixed-methods approach to develop and validate a CPG for SBE treatment in the Brazilian context. An overview of the methods is presented in Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), a tertiary healthcare unit that treats SBE patients in the western Amazon region, and one from the Instituto Butantan (IBU), the major antivenom producer in the country, which also treats SBE patients in the city of São Paulo) was established to elaborate the first version of the CPG and to coordinate the validation process.A steering group composed of three PhD-level researchers with a track record  in the field of clinical research and care of SBE patients , seven nurses , three clinical laboratory scientists, three educators , two psychologists , one herpetologist, one clinical epidemiologist and two clinical research experts.The plan for the development of the CPG began with the identification of existing related guidance for SBE management in Brazil and the definition of the scope of the CPG, which included objectives and potential sections.Bothrops, Lachesis, Crotalus and Micrurus), as well as the available antivenoms and their dosages according to SBE severity. The Brazilian Ministry of Health (MoH) guideline was originally created based on expert opinion considering the experience of patients treated in hospitals, under medical supervision. The guideline does not address pre-hospital care and first aid; antivenom storage, preparation and administration; wound care; ancillary treatment of different local and systemic manifestations; referral to higher complexity healthcare services; discharge criteria; clotting time procedure; and reporting of cases to epidemiological surveillance systems. A literature search via MEDLINE and LILACS on 31 January 2020 (in Portuguese and English), which used the descriptors (snakebite OR snake bite OR snake envenomation OR ophidian accident OR ophidian bite OR ophidian envenomation OR snake accident) AND (care package OR treatment guideline OR treatment package) AND Brazil, did not provide any additional published guidelines for the treatment of SBEs in Brazil.The Brazilian Ministry of Health has an official guideline with general recommendations for the management of SBEs and envenomations by other venomous animals . This guThe first version of the CPG was written with 13 chapters . It is nProfessors of graduate programs in tropical medicine and clinical toxicology were selected and invited to participate as expert judges for this study, as long as they act in lines of research related to SBEs. Health staff trained in the care of SBE patients in tertiary hospitals were also invited to participate. Initially, researchers and professionals identified from scientific publications retrieved from MEDLINE with publications within the last 5 years were invited. Additionally, the indication of experienced health professionals  by these researchers was requested. Some hospitals were also contacted to obtain recommendations. The aim was to obtain a culturally and geographically diverse sample that could evaluate the validity and reliability of the revised care information package in Brazil. The committee was further divided into two groups: Group 1 (G1) (expert judges with academic experience) and Group 2 (G2) . The inclusion of the judges in G1 was established by the achievement of a score of five points in the following items: professional training, experience and scientific publications in the field of SBEs). For G2, the same criteria were considered, with a requirement of reaching a minimum score of three points, as well as having at least 2 years of experience in the treatment of SBE patients  Table 1Table 1.The invitation was made via an email sent to the potential judges, which also had the first version of the CPG attached in portable document format (PDF) and a link (Google forms) with the informed consent form. In case of no response within 20 days after the invitation, the judge was not included. Judges were excluded if they did not return the fully completed and legible instrument within 20 days after the validation instrument was sent.The validation instrument used was a questionnaire organized into three parts: the judge’s details; orientations for filling in the questionnaire; and three blocks with items on the (1) objectives, (2) structure and presentation and (3) relevance of the CPG. These items were evaluated using a Likert-type scale, with space for comments in each block. Each judge was able to express their assessment in the three blocks using scores of 1 to 4 . In addition to this validation instrument, the judges were also asked to send any comments they considered pertinent to the improvement of the care information package. A second version of the care information package was produced based on the scores obtained after applying the validation instrument and accepting the judges’ comments and opinions.In order to validate the care information package with the target audience, doctors and nurses working in the health service of the municipalities of Careiro da Várzea, Ipixuna and Boa Vista do Ramos, in the state of Amazonas, were invited to a 5-day (28 June to 2 July 2021) meeting in Manaus. The professionals were appointed by the municipal health managers and agreed to participate. The second version of the care information package was presented to them through lectures and discussions of real clinical cases. The professionals who completed at least 75% of the meetings were invited to participate in focus groups with a maximum of 10 participants per group. Participants who agreed to participate signed a consent form after an explanation of the study’s objectives and procedures.Prior to the sessions, areas of interest to be discussed during the focus groups were specified by the research group, which was led by the steering group. A semi-structured interview guide was developed and piloted on a smaller sample of volunteers . Each foAfter the evaluation of the CPG’s semantics by the target users, its final version was elaborated by analyzing the suggestions in order to improve content and structure via a more comprehensive language and better format style. The final version of the CPG was revised by a Portuguese language teacher.Descriptive statistics were used for characterizing study participants and to obtain the content validity index (CVI) for the expert evaluation of the CPG content . The CVIThe qualitative analysis was carried out through a thematic content analysis, with the elaboration of categories that emerged during the analysis process after the previous reading of the transcripts. Data source triangulation  was used during the analysis, and the codebook was created in MAXQDA software by two researchers (W.M.M. and F.M.) independently. The discrepancies in the coding were resolved with discussion to reach a consensus.Results were presented according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) .Invitation letters were sent to 51 potential judges, which yielded 24 acceptances. In all, 20 returned the form duly filled out and were analyzed; 12 judges had academic expertise in clinical research of SBEs and 8 had SBE management expertise. The age of the judges ranged from 29 to 66 years, and professional experience ranged from 3 to 40 years. Judges from the states of Amazonas, Acre, Tocantins and São Paulo and from the Federal District were included. All have master’s or doctoral degrees and professional experience as university professors and as technical consultants in the area of infectious and tropical diseases and the epidemiology and clinical treatment of SBEs.n = 20) and the total scores of the instrument (n = 20), a total of 400 possible evaluations were obtained. The content verification index (CVI) score was 90%, 89% and 92% in blocks 1 (objectives of the CPG), 2 (structure and presentation) and 3 (relevance), respectively, thus classifying the CPG as valid in relation to content  agreed to participate in the focus groups. Data collection was performed in three focus groups . A purposeful sample of professionals working in health units located in the three municipalities  in the state of Amazonas, western Brazilian Amazon, was included. The participants were aged between 24 and 64 years and had an average of 3 years of professional experience.Theme 1, knowledge acquired in the current meeting, and Theme 2, recommendations for the improvement of the care information package.During the qualitative analysis, two themes related to semantic validation emerged: In this theme, the quotes indicated new information that the participants had acquired during the CPG presentation. Participants cited incorrect practices in first aid, which they will no longer commit, the advantage of having knowledge about identification of snakes, knowledge of premedication regimens to prevent early adverse reactions, the unnecessary prophylactic use of antibiotics, the importance of knowing the epidemiology for diagnosing the type of envenomation, procedures for wound care, patient follow-up and case reporting. These points are summarized in Participants recommended inclusions in the CPG that are focused on the antivenom, laboratory tests, concomitant medications and layout of the CPG document .At the end of the semantics validation, recommendations from the target audience were incorporated into the second version of the CPG. The final version has 46 pages, including a cover page, a summary, a presentation page, 13 chapters  and literature references. The document also includes 8 figures, 12 flow charts, 11 tables and the form used for snakebite reporting .A CPG for SBE care using community health centers in the Amazon Forest was deemed clinically relevant and valid, as demonstrated by experts’ ratings. This is aligned with the WHO’s strategy for SBE prevention and control which aims to reduce the numbers of deaths and cases of disability by 50% before 2030, improving overall care for patients . In the In Brazil, despite the advances made to achieve self-sufficiency in antivenoms of a high standard and the expansion of a free-of-charge antivenom treatment network, access to SBE treatment is still not available to the most vulnerable parts of the population, which are those that inhabit remote areas of the country, especially in the Brazilian Amazon ,5. StronFrom a perspective of decentralizing antivenom treatment to community health centers located in remote areas, the clinical utility of these culturally validated care information packages is even more evident, and it is essential to standardize the care provided to patients. Even in community health centers that do not perform antivenom treatment, it is important to have professionals trained in first aid and the preparation of the patient for transport. However, in general, official guidelines focus almost exclusively on antivenom choice and dosage, without mentioning supportive care. In this study, the panel of expert judges and the target audience approved the fact that the care information package has included this content, which is not usually included in training. In the context of many community health centers, where antivenoms are currently not available, we adapted the CPG, namely in the sections that focused on first aid, wound care and referral of the patient to the higher-level health units, in order to provide users with treatment solutions that are practical for this level of assistance, painkillers and primary wound care, which could provide more time for emergency cases and subsidize comfortable transportation to higher-level health units.In general, physicians and nurses assessed themselves as having very poor knowledge of SBEs, thus resulting in insecure actions and even utilizing incorrect patient care practices. In other situations, professionals were concerned only with referring patients to the nearest hospital units as quickly as possible, in an attempt to free themselves from responsibility. In these cases, most of the time, no care was taken except to activate the available means of transport. It is possible to infer from the professionals’ statements that they recognize that the antivenom is essential for the SBE treatment, but no other first-aid procedure is understood to be necessary to alleviate the patient’s suffering.Healthcare professionals have doubts as to the effectiveness of non-evidence-based traditional practices, such as those used by the indigenous peoples and riverine populations in the Amazon. Therefore, in the CPG, it was necessary to inform health professionals that some of these practices are ineffective or even harmful (such as tourniquets and incisions), or have unproven effectiveness (such as plant-derived preparations), though at the same time taking care to respect the culture and traditional knowledge of the populations. Some of this information was clearly unexpected by the professionals, who highlighted the need to add these clarifications to the CPG. Participants attributed the low level of knowledge and insecurity to the lack of training they received during their undergraduate courses or training before being referred to work in areas of occurrence of SBEs. In the Brazilian Amazon, the lack of proper training for health workers also results in patients’ resistance to care. Even when antivenom is available locally, some patients may perceive that the quality of care will be better at more distant units and travel very long distances from home  .Health professionals in remote settings may feel insecure about treating SBEs, due to the fear of not being able to manage antivenom-associated early adverse reactions . KnowledAs for the topic of disseminating knowledge, the participants demonstrated a great interest in propagating all the items of the CPG to the other professionals at their institutions, as well as to the community through health education. This needs to be instituted as a polity action within each municipality so that it is disseminated, known and put into practice by all the actors that make up the health secretariats and their basic health network centers.Bothrops envenomations (~90% of the snakebites in the region) were underdosed [In Brazil, irrational use of antivenoms is common, with a high frequency of both over- and under-prescribing. Snakebites that do not require antivenom treatment, such as dry bites, in which no venom is injected , and bitderdosed . In thisderdosed ,22.In Brazil, an excessive rate of preventable losses still occurs as a result of there being no specific training in the storage and administration of antivenoms and their expiration due to a lack of proper inventory control . In the Another common practice reported by professionals was the preemptive use of antibiotics. This intervention is not supported by clinical trials  and endsThis study has methodological strengths and limitations that should be considered when interpreting the results. Firstly, evaluations by the judges and health workers about the usefulness, benefits and drawbacks  of the CPG are probably influenced by the academic judges and the practitioners’ current work routine and their working context. The expert judges have experience in the field, high-level academic knowledge and vast professional experience, which indicates the extent of the degree of expertise appropriate to the validation of the protocol. Another significant point in relation to the profile of the expert judges concerns their origins, since they work in the northern, southern-central and southeastern regions, which provided diverse and contextualized contributions, thus enriching the inferences given by the professionals in relation to the subject of the study. However, most professionals who participated in the focus groups had little experience in managing SBE patients. If on one hand this prevents them from giving suggestions with a greater technical background, on the other hand these professionals demanded detailing of all the procedures, with illustrations, workflows and improvement in writing of the texts.Secondly, no gold standard has yet been introduced for instruments used to study the concept of ancillary treatments for SBEs. In general, all the guidelines only focus on AV. Thus, comparison with other instruments relating to other measurement properties, such as cross-cultural and criterion validity, is limited. Thirdly, the recruitment process of study participants was challenging due to the work pressure of the expert judges and the health workers.In order for people to be successfully treated and recover from SBEs, they require access to good-quality antivenoms and other care procedures that may be necessary . In Braz


The rapid development of the vaccine and the infodemia have challenged communication about COVID-19 vaccines. This study aims to characterize—through the experience of vaccinators—the challenges faced during COVID-19 vaccination consultations and the communication strategies adopted. A qualitative study was conducted on COVID-19 vaccinators in Tuscany, Italy. Face-to-face interviews were conducted and examined by thematic analysis. In total, 30 vaccinators were interviewed. Four main themes emerged. The first highlighted distinct profiles of users’ attitudes toward COVID-19 vaccination. Barriers and promoters of vaccine uptake emerged in the second theme: concerns over the vaccine, excessive exposure to information, and a lack of clear guidance from institutions were the main factors behind hesitancy. The third theme highlighted users’ information-seeking behaviors; vaccinators observed that users ideologically opposed to the vaccine (IOV) unconsciously seek information that confirms their theories. The last theme comprised communication strategies for dealing with hesitancy. Empathy, first-hand examples, transparency, and tailored communication style appear to be effective in building vaccine trust. Lastly, the impossibility of developing a decision-making partnership with IOVs was noticed. These findings may help to better characterize public attitudes toward COVID-19 vaccination and highlight key communication principles and strategies to foster vaccine confidence. Vaccination is the main tool for the primary prevention of infectious diseases and among the most cost-effective public health measures available ; the immNumerous factors have influenced the level of trust and adherence of the population to the vaccine campaign and to other mitigation measures for COVID-19; in particular, the novelty of the disease, the unusually rapid vaccine development, the use of new vaccine technologies, and the rapid and uncontrolled spreading of information and misinformation  were reported among the main factors . FurtherDuring the COVID-19 vaccination campaign, healthcare workers, who represented the main point of contact for the population, faced a threefold challenge: adapting to government and institutional directives, justifying the uncertainty to users, and confronting a more vaccine-hesitant population. Evidence shows that frontline healthcare workers are among the most trusted sources of vaccination information and advice, and thus, one of the main factors in the success/failure of a vaccination program . MultiplCarefully planned and proactive communication is one of the principal tools at the disposal of healthcare workers to improve vaccine acceptance during vaccination consultation ,13; effeIn order to deal with hesitancy and vaccination refusal, it is of pivotal importance—both for institutions and healthcare workers—to develop communication strategies based on the experiences of those who worked on the front line during the vaccination campaign. Indeed, vaccinators represent a privileged point of view that may allow us to capture the different nuances of vaccine attitudes of users throughout the vaccination campaign and identify the determinants associated with them. Furthermore, through their experience, it is possible to comprehend the communication needs of different categories of users and define which strategies were the most effective during the evolving epidemic context. Therefore, the present study aimed to characterize public attitudes toward COVID-19 vaccination faced by vaccinators and factors influencing vaccine confidence and identify communication strategies adopted during vaccination consultation by vaccinators.The study was conducted according to the Helsinki principles, and informed consent was obtained from all subjects involved in the study.National Strategic Vaccine Plan for the Prevention of SARS-CoV-2 Infections, which gave priority to the elderly and the frail [Italy has been one of the first European countries to be severely hit by the COVID-19 pandemic . To conthe frail . Once moUnità Speciali di Continuità Assistenziale—special continuity care units, a service in charge of the vaccination of frail people at home and in nursing homes, as well as of refugee and migrant populations).This qualitative study was conducted on a sample of healthcare workers involved in the COVID-19 immunization campaign in the Tuscany Region ; in particular, vaccinators from different services were recruited: mass-vaccination campaigns (HUB), general practices  vaccinated the frail and elderly, and subsequently, other users, too), hospital vaccination services , and USCA services  in the vaccination campaign were excluded. The participant recruitment was stopped when thematic saturation was reached; this was discussed and agreed upon among the authors. Participants were contacted and interviewed between April and November 2022.All participants were informed about the purpose of the study, and informed consent was obtained from all of them prior to their participation in the study. Data were collected through in-depth face-to-face interviews jointly conducted by two researchers . No relationship was established prior to the study commencement between participants and interviewers. The research team developed a semi-structured interview to explore the following domains: users’ information-seeking behaviors, perception of COVID-19 vaccination, and communication strategies implemented during consultation. The interviews lasted for about one hour. In order to test the interview guide, a pilot test was conducted; interviewers were trained not to suggest value judgements.All the interviews were audio recorded and transcribed verbatim; no notes were taken during the interviews by the interviewers. Participants were informed that data from interviews would be collected in an anonymous form. To examine the content of the corpus, an inductive thematic analysis was conducted. The first phase included repeated readings of the interviews to familiarize the interviewers with the data. Subsequently, a coding framework (codebook) was developed to organize the data-coding process. After the examination of the codes, the subsequent step involved the identification of the themes emerging from the data. Codes and themes were identified from the data by three authors  independently and revised jointly. Disagreements on coding and themes were resolved involving a fourth author (V.L.) where necessary. The names of themes to be included in the final report have been reviewed by all the researchers. To facilitate data management and coding, the transcripts were uploaded and analysed with Iramuteq software .Furthermore, determinants of vaccine acceptance/hesitancy concerning COVID-19 vaccination that emerged from interviews were identified and traced back to the conceptual model developed by the WHO Strategic Advisory Group of Experts (SAGE) . SpecifiThe interviews were submitted to a total of 30 vaccinators  aged between 25 and 71 years old. The characteristics of the vaccinators are summarized in From the inductive thematic analysis of the interviews, four main themes emerged; below, the four identified themes are summarized.Interviews with vaccinators revealed six categories of users’ vaccine attitudes: eager to get vaccinated, compliant with the recommendations, information/reassurance seekers, wait-and-seers, unwillingly vaccinated to avoid work and social restrictions, and ideologically opposed to the vaccine.The respondents reported that the preponderance of the population was eager to get vaccinated; this attitude was related to a generally high level of confidence in the health system, science and vaccine efficacy and was observed particularly in the elderly and young adults for different underlying reasons, i.e., perceived susceptibility to COVID-19 and regaining social life, respectively.Users compliant with the recommendations were described as those who were vaccinated on time without any doubt or concern and who did not want any further information, mainly because they trusted science and were willing to pursue their duty as citizens.Other users delayed vaccination for fear of the vaccine; two distinct categories of such hesitant users were described: reassurance seekers and wait-and-seers. The first group openly shared their fears during the consultation, while the wait-and-seers were those mainly observed in the early phases of the vaccination campaign who waited to see the effects of the vaccine on those who received it; a substantial distrust in science and institutions was at the basis of this attitude. Lastly, some users reported a high level of mistrust in the health system and institutions and believed in conspiracy theories. These users frequently did not trust the scientific community even before the pandemic; the rapidly evolving scientific evidence and contradictory directives for pandemic management exacerbated this attitude. Some of these users eventually became vaccinated to avoid work and social restrictions, while others firmly pursued their beliefs and never became vaccinated. Generally, users belonging to these two categories were middle-aged, had an average to good education level, and belonged to the middle socio-economic class. The most relevant quotations for this theme are summarized in All the determinants of vaccine hesitancy and confidence that emerged from the interviews were categorized according to the SAGE Working Group model. Factors identified as either barriers or promoters of vaccine confidence are shown in The main barriers which lowered vaccine confidence were related to the rapid development of a new vaccine and the general belief that there were not enough clinical trials to guarantee vaccine safety. In particular, a widespread tendency among users has been to implement a heuristic risk-benefit calculation rather than one based on scientific evidence. Moreover, excessive exposure to mass-media information and a lack of clear guidance from institutions fostered users’ concerns (see theme 3).COVID-19 normative/institutional restrictions, perceived disease severity, mode of delivery and accessibility of COVID-19 preventive services were identified as major promoters.Lastly, socio-economic, religious, and cultural factors, as well as sex, did not emerge as significant determinants. The most relevant quotations for this subtheme are summarized in Vaccinators reported an evolution of users’ vaccine confidence during the different pandemic phases. In the early stages of the pandemic, when the vaccine was not yet developed, the perception of the disease severity was very high, and people strongly desired the possibility of having an effective vaccine. This explains the positive attitude observed at the beginning of the vaccination campaign. Vaccine confidence increased even more during the first phases of the vaccination campaign as more users became vaccinated without relevant side effects reported. In the subsequent stages, vaccine confidence increase was hampered and probably reversed due to various reasons. The first was related to the report of some cases of severe vaccine side effects amplified by the mass media. The second was the presence of different types of vaccines, with some believed to be safer or more effective; this generated a widespread willingness to opt for the preferred one, even though it was not possible to choose among vaccines. The third is related to the reduced perception of COVID-19 disease severity when a high level of immunization coverage in the population was reached. The fourth is related to the misleading messages—both from mass media and institutions—regarding the fact that the vaccine could protect from contracting the infection led to an increase in vaccine hesitation when infections in vaccinated people were raised. Furthermore, pandemic fatigue led to a general demotivation toward recommended preventive measures, including vaccination. In the most recent stages of the vaccination campaign, with the almost complete removal of containment measures and the return to a pre-COVID-19 social life, vaccination was perceived as safe as other routine vaccinations. The most relevant quotations for this subtheme are summarized in Interviews highlighted that users generally utilized horizontal communication channels  and very few used vertical and official communication channels . In this context, the main source of information for the elderly were mass media, general practitioners, and relatives, while the Internet and social media were mainly used by the young and middle-aged population groups; the population group aged 45–60 years was perceived more vulnerable to the Internet and social media misinformation. Some vaccinators observed that a frequent information-seeking behavior unconsciously applied by users was picking the sources that confirmed their presumptions and avoiding the ones that could refute or belittle their beliefs ; this caused a bias and led an individual to validate the desired thesis, even when false. Interestingly, interviewees noticed that, although this phenomenon was common to most users, it was stronger in those who showed contrary or distorted ideas about vaccination.Lastly, vaccinators from the HUB service highlighted that adherence to the vaccination campaign could have benefited from a more proactive contribution in terms of vaccine advocacy from the general practitioners, especially in people aged below 60 years. Indeed, it was reported that they would have benefited—both in terms of user vaccine confidence and time spent in consultation—by also having these users previously informed by the most proximal and trusted health information source, i.e., the general practitioner. The most relevant quotations for this subtheme are summarized in Vaccinators perceived that users had access to an enormous quantity of information about the COVID-19 vaccine and that the vaccine topic became of public wisdom as never before. A discrete proportion of users were reported to be highly impacted by this unfiltered amount of information, misinformation, and disinformation; this fuelled uncertainty, a general sense of helplessness, and, consequently, fertile ground for vaccine hesitancy and conspiracy theories.Furthermore, vaccinators reported a lack of guidance from institutions in terms of crisis communication to the population; users were confused by the inconsistency and the rapidly evolving institutional directives on the pandemic and vaccine campaign. This, together with the infodemia, further increased mistrust and vaccine hesitation and undermined the credibility not only of the institutions but also of the vaccinators, who have felt abandoned in the task of informing users. Vaccinators noticed that more consistent, transparent, and coordinated communication from the involved public institutions would have been fundamental to strengthening population trust and reducing the opportunity for rumours to spread, ultimately facilitating their work. Lastly, vaccinators highlighted the limits of the COVID-19 vaccine communication campaign that addressed the entire population indiscriminately, leaving a sense of vagueness. The most relevant quotations for this subtheme are summarized in Empathy: it emerged how crucial it was to have active and non-judgmental listening, to make the user feel understood, and to ask for users’ feedback about the information provided during the consultation. Furthermore, putting themselves on the same level as the user was regarded as a useful strategy by several vaccinators, with some of them saying that sharing their own experience and initial concerns about the vaccine reassured hesitant users. Lastly, another strategy reported to reassure hesitant users was to involve other users’ trusted medical health professionals so as to make them feel truly heard and understood.Transparency: transparency and honesty about scientific evidence was deemed essential to establishing a relationship of trust with users. Furthermore, it highlighted the importance of clearly admitting the uncertainty of evidence when they were not strong enough. This situation occurred, for example, in the case of the vaccination of pregnant women at the beginning of the vaccination campaign.Highlighting the balance between risks and benefits: vaccinators found it useful to stress the high level of vaccine efficacy and safety on the one hand while highlighting the risk of getting COVID-19 on the other hand. The use of everyday life examples, such as pointing out that the COVID-19 vaccine had similar or fewer risks than other commonly used drugs, was useful in overcoming fear and hesitation. Since one of the most common fears was the unknown long-term effects of the vaccine, pointing out that COVID-19 also may have long-term effects was proven useful. Furthermore, highlighting specific aspects in terms of personal or familiar clinical risks helped to make users understand that vaccination is particularly useful for their case.Adopting a personalized approach: a user-centered approach was frequently mentioned in dealing with vaccine hesitancy. This required exploring reasons behind hesitancy without being judgmental and understanding the user’s belief and attitude toward health and vaccines in order to adapt the communication style. If the user shows beliefs and values in line with vaccine recommendations, reporting scientific data and evidence was reported to be persuasive; in the case of contrasting convictions, emotional stories were reported to be more effective.All the vaccinators reported that their professional opinion matters, and they felt influential in the user decision-making process. Several communication strategies for dealing with hesitant users emerged from the interviews; key principles and effective communication strategies for dealing with hesitant users were mainly inherent in the following areas:Lastly, many vaccinators pointed out that explaining the importance of vaccination in order to achieve community immunity  did not influence the vaccination choices; moreover, all the vaccinators did not use or share communication-supportive materials during the consultation since they noticed that users preferred to hear information directly from them.As for users ideologically opposed to the vaccine, two different cases of dealing with this category emerged: the case in which they were actively called by their physician to receive the vaccination and the case in which they spontaneously came up to the vaccination HUB . In both cases, they were not open to discussion, hardly or never deviated from their beliefs, and sometimes verbally harassed vaccinators. Apparently, there is no effective communication strategy for developing an informed decision-making partnership. Interestingly, in the case of the general practitioners, the divergent opinions on the vaccine with users ideologically opposed did not hamper the patient-physician relationship in other health areas as mainly they believed that the G.P. themself was a victim of a conspiracy from institutions/pharmaceutical companies. Given the high levels of tension involved in the conversations with this type of user, avoiding dismissing and debating and instead providing clear and concise recommendations was deemed essential as a first approach to building trust; this may help in creating further opportunities to discuss the vaccination more openly. The most relevant quotations for this theme are summarized in Several studies demonstrated that receiving pertinent information from health operators may increase vaccine acceptance ,9,10,11.The interviews revealed several profiles of users’ attitudes toward COVID-19 vaccination. The profiles described reflect the vaccine hesitancy continuum model described for routine vaccinations , with soInterestingly, all the vaccinators described a similar trend of vaccine confidence over the course of the vaccination campaign (depicted in Concerns over vaccine safety and fear of unknown long-term health consequences were among the main factors observed behind vaccine hesitancy for the COVID-19 vaccine. These factors were mainly related to the rapid development of the vaccine and to the novelty of the mRNA technology, as the main belief was that the vaccine had not been tested enough. These findings are in line with other studies carried out in different countries and settings ,32,33,34Findings also showed that these concerns and beliefs were highly exacerbated by the lack of clear guidance and communication from the government and competent health institutions and by the infodemia. Indeed, the experience of vaccinators highlighted that the COVID-19 pandemic had the characteristics—such as the novelty of the disease, the evolving situation, the need for rapid adaptations of policies and public health measures—to create fertile ground for the spread of rumour and that users were not able to navigate the huge amount of available information. Misinformation and disinformation created fears and discouraged people from their decision to get the vaccine ,39,40. ADuring consultations with patients, vaccinators highlighted that their opinion matters and felt they were a trusted source of information for hesitant users. This finding confirms that first-line healthcare workers have a prominent role in guiding hesitant users and in increasing vaccine acceptance ,9,10,11.Interestingly, our findings clearly characterize a subgroup of users that were ideologically opposed to the vaccine; in line with other studies, our findings showed that these users had an a priori refusal of the vaccines, a high level of distrust in conventional medicine, health system and institutions, and a tendency to believe in conspiracy theories ,55. In tThe present study had several strengths and limitations. As for the strengths, the maximum variation purposive sampling allowed to include the widest range of perspectives possible—i.e., vaccinators working with different types of users and in distinct services based in urban and rural contexts—so as to explore the topic from different angles and identify both common patterns and variations. Furthermore, the study included vaccinators that continuously vaccinated for at least one year; this allowed us to have a solid overall perspective on the evolution of vaccine confidence over time and on the challenges faced in the various vaccination campaign phases. As far as the limitations are concerned, the sample was selected from only one Italian region. Furthermore, as the study is based on data from face-to-face interviews, a social desirability tendency of participants cannot be dismissed; however, interview questions were specifically developed in order to be neutral, and interviewers were trained not to suggest value judgements or interpretations.Our study explored the privileged viewpoint of vaccinators on the COVID-19 vaccine campaign. Our findings highlighted aspects and trends of user vaccine confidence that could recur in cases of future pandemics or rapid vaccine development, especially in the context of mass-vaccination campaigns and high public and media attention. At the population level, consistent, targeted and coordinated vaccine institutional communication is needed in order to build trust with the population and to empower the frontline healthcare workers involved in the vaccination campaign. At the individual level, our findings confirm that frontline operators are essential in dealing with vaccine hesitancy and in increasing vaccine acceptance. Several key communication principles and strategies were identified to foster vaccine confidence; while, although it may be proven difficult, avoiding debating and providing brief and clear recommendations may serve to start building trust with users ideologically opposed to the vaccine and to leave the door open for further occasions. Further studies that include user perspectives are needed in order to better identify leverages and strategies to engage with this population subgroup.