<section id="sec1" style="margin: 0px 0px 8px; padding: 0px;"><p id="p0035" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">Childhood vaccines reduce mortality and morbidity rates and decrease healthcare costs through the prevention of vaccine-preventable diseases</span><span style="font-family: Helvetica; font-size: 14px;">. However, research suggests that children with Autism Spectrum Disorder (ASD), hereafter referred to as ‘autism’, a neurodevelopmental condition affecting between 1 and 4% of the population in Australia</span><span style="font-family: Helvetica; font-size: 14px;">, are less likely to be fully vaccinated than children without an autism diagnosis</span><span style="font-family: Helvetica; font-size: 14px;">. Vaccine uptake in younger siblings of autistic children has also been shown to be lower than amongst the general population.</span></p><p id="p0040" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">Vaccine hesitancy may be one potential reason for lower vaccine coverage in this population. A key contributor has been the perceived link between autism and the measles, mumps, and rubella (MMR) vaccination which has been falsely propagated since Wakefield's flawed and subsequently retracted study in the&nbsp;</span><em style="margin: 0px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">Lancet</span></em><span style="font-family: Helvetica; font-size: 14px;">. Despite no supportive evidence of a causative link, Wakefield's study has continued to impact caregivers' vaccine decision-making through fear of causing autism. Two studies, conducted around the time the&nbsp;</span><em style="margin: 0px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">Lancet</span></em><span style="font-family: Helvetica; font-size: 14px;">&nbsp;study was retracted in 2010, found that belief in a vaccine-autism link was a strongly influential factor in caregivers' decisions to delay or not vaccinate their autistic child or their child's siblings, once the autism diagnosis was made</span><span style="font-family: Helvetica; font-size: 14px;">. In a more recent study, caregivers of autistic children were more likely to be influenced by the idea of a vaccine-autism link compared to caregivers of children without an autism diagnosis, despite conveying knowledge of a lack of evidence to support a link</span><span style="font-family: Helvetica; font-size: 14px;">. Recent research from Australia found that caregivers' perceptions of a vaccine-autism link no longer impacted vaccine compliance in the general population</span><span style="font-family: Helvetica; font-size: 14px;">. However, whether or not this shift extends to caregivers of autistic children in an Australian context has not yet been studied. Because most autistic children are diagnosed with autism at around 4 years of age</span><span style="font-family: Helvetica; font-size: 14px;">, well after their 12- and 18-month MMR vaccines are due in Australia, this concern may be more reflected in caregivers' decisions about vaccinating their autistic child's younger siblings. It may also affect their decisions about adolescent, influenza, or COVID-19 vaccines for their autistic child.</span></p><p id="p0045" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">Apart from vaccine hesitancy, under- or non-vaccination of autistic children may be due to other personal or environmental factors. Challenges include autistic social communication and sensory processing differences compounded by unfamiliar expectations, strong sensory stimuli, and potentially painful experiences in healthcare settings</span><span style="font-family: Helvetica; font-size: 14px;">. Autistic children and adolescents also present with a high prevalence of anxiety disorders</span><span style="font-family: Helvetica; font-size: 14px;">, particularly specific phobias and medically related fears&nbsp;</span><span style="font-family: Helvetica; font-size: 14px;">likely to influence the vaccination experience. Caregivers' concerns relating to their child's distress when receiving vaccinations in the general population have been documented before</span><span style="font-family: Helvetica; font-size: 14px;">, as well as behavioral and emotional challenges faced by children with disabilities in special schools</span><span style="font-family: Helvetica; font-size: 14px;">. However, there is currently a limited understanding of the impact of autistic children's sensory challenges, behavior, distress, and anxiety on caregivers' decisions to vaccinate their autistic children.</span></p><p id="p0050" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">Our study aimed to explore the views and experiences regarding childhood and adolescent vaccination among caregivers of autistic children in Australia using a qualitative research approach. These data will (a) improve the understanding of the factors that impact vaccine decision-making and the vaccination experiences for autistic children and their families and (b) identify child- and family-centered strategies to improve vaccine uptake in this population.</span></p></section><section id="sec2" style="margin: 0px 0px 8px; padding: 0px;"><h2 id="sectitle0025" class="u-h3 u-margin-l-top u-margin-xs-bottom" style="margin-right: 0px; margin-left: 0px; padding: 0px; color: rgb(80, 80, 80); margin-top: 32px !important; margin-bottom: 8px !important; font-size: 1.2rem !important; line-height: 1.333 !important;"><span style="font-family: Helvetica; font-size: 14px;">&nbsp;<b>Methods</b></span></h2><section id="sec2.1" style="margin: 0px 0px 8px; padding: 0px;"><h3 id="sectitle0030" class="u-h4 u-margin-m-top u-margin-xs-bottom" style="margin-right: 0px; margin-left: 0px; padding: 0px; color: rgb(80, 80, 80); margin-top: 24px !important; margin-bottom: 8px !important; font-size: 1rem !important; line-height: 1.4 !important;"><span style="font-family: Helvetica; font-size: 14px;"><b>Study setting and participants</b></span></h3><ul><li style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">This study is part of a larger mixed methods study called Measuring Immunisation in NeuroDiverse populations (MIND). </span></li><li style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">The MIND study aimed to assess vaccine hesitancy and uptake in families of children with autism, Down syndrome, and children in the general population with no developmental concerns. Participants were recruited between May 2020 and May 2021 through social media and online autism and Down syndrome support networks.</span></li><li style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">All participants were eligible to take part in the MIND study if they were caregivers of an autistic child or a child with Down syndrome under 18 years and lived in Australia. Interested participants were invited to complete an online survey to assess their views on vaccination and factors that may affect their decisions about vaccinating their children.</span></li><li style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">Participants for this study were selected from a subsample of 65 caregivers who completed the MIND survey in the autism cohort and provided optional consent to be contacted to take part in a qualitative interview to further explore their vaccine decision-making and experiences. The 65 participants were sampled according to the age of the eldest autistic child, the child's autism severity (mild, moderate, or severe, according to caregiver self-report in the survey), sibling composition, caregiver socio-economic status and childhood vaccination practices (i.e. whether caregivers chose to vaccinate, delay or not vaccinate their child).</span></li><li style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;"> We applied a purposive maximum variation sampling technique&nbsp;</span><span style="font-family: Helvetica; font-size: 14px;">to support the heterogeneity of the sample and an understanding of vaccination experiences among a range of families. Recruitment continued until no new relevant information was arising during subsequent participant interviews.</span></li></ul><p style="margin-bottom: 16px; padding: 0px;"><b><span style="font-family: Helvetica; font-size: 14px;"><br></span>&nbsp;Procedure</b></p></section><section id="sec2.2" style="margin: 0px 0px 8px; padding: 0px;"><p id="p0065" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">The first author (KL, female autistic research assistant, BSc GradDipPsych, with a background in psychology research) and last author (JK, female research fellow, Ph.D. public health with a background in vaccine acceptance and communication research) completed recruitment and data collection remotely in July and August 2021. Initial recruitment phone calls were made to introduce the study and invite participants to take part in the interview. Participants who agreed to take part were emailed a Plain Language Statement and Consent Form and provided their written consent before the interview. Participant demographic information was obtained from the MIND survey data once written consent was obtained. Interviews took place via phone call or video conference call according to participant preference and lasted approximately 30–45&nbsp;​min. Remote interviews afforded the capture of rich data from the inclusion of participants from a national sample, as well as increased flexibility to schedule and reschedule interviews.</span></p><p id="p0070" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">The first author and last author developed and applied a semi-structured interview guide&nbsp;</span><span style="font-family: Helvetica; font-size: 14px;">that steered participants to speak about key topics of research interest while also allowing participants the space to explore their personal experiences and generate novel insights about the research topic</span><span style="font-family: Helvetica; font-size: 14px;">. To begin the interview, participants were asked to provide additional demographic information not captured in the original MIND survey, including state of residence, the child's sibling composition, and the child's current educational setting. To prompt discussion, participants were asked to describe their journey to obtaining a diagnosis of autism for their child. Participants were then asked questions about their perceptions of childhood vaccinations, their prior experiences vaccinating their autistic child as well as their considerations for future vaccinations and for vaccinating their child's siblings. For participants who had more than one autistic child (n&nbsp;​=&nbsp;​7), participants were provided the opportunity to share the vaccination experiences of their other autistic children. All participants received a $10 gift card as a recognition of their time. Interviews were audio-recorded and interviewers wrote notes following each interview to reflect on salient ideas.</span></p></section><section id="sec2.3" style="margin: 0px 0px 8px; padding: 0px;"><h3 id="sectitle0040" class="u-h4 u-margin-m-top u-margin-xs-bottom" style="margin-right: 0px; margin-left: 0px; padding: 0px; color: rgb(80, 80, 80); margin-top: 24px !important; margin-bottom: 8px !important; font-size: 1rem !important; line-height: 1.4 !important;"><span style="font-family: Helvetica; font-size: 14px;"><b>&nbsp;Data analysis</b></span></h3><p id="p0075" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">All interviews were deidentified and professionally transcribed. A reflexive approach was applied throughout the study whereby the first author and last author regularly met to discuss their own experience, attitudes, and knowledge about autism. These discussions occurred in the context of planning the study, discussing the interview process, coding, and analysis, and acknowledging the active role of researchers in interpreting the data</span><span style="font-family: Helvetica; font-size: 14px;">. The interview data were analyzed in an inductive way&nbsp;</span><span style="font-family: Helvetica; font-size: 14px;">to capture new and current local knowledge through participants’ exploration and elaboration of key concepts relevant to their unique views and experiences vaccinating their autistic children.</span></p><p id="p0080" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">The first author checked the accuracy of all transcripts by comparing them with audio-recorded interviews. Transcripts were imported into the software program NVivo 12 </span><span style="font-family: Helvetica; font-size: 14px;">for storage and organization. Thematic analysis was conducted using the&nbsp;</span><span style="font-family: Helvetica; font-size: 14px;">six-phase framework to identify key patterns in the data. During phases one and two, the first author read and re-read transcripts and coded data in NVivo 12. During phase three, the first author organised all codes into initial themes and sub-themes. In phases four and five, the first and last authors met to review and refine the initial themes and sub-themes, then defined and named themes representing a unique and discrete aspect of the data while relating to, but not overlapping with, other themes. In phase six, the first author wrote up and reviewed the final themes to check for logical connection. Final themes and sub-themes were reviewed by all authors. Quotes from participants, corrected for grammar, are included to illustrate sub-themes. The symbol ^ on participant numbers indicates caregivers who had more than one autistic child.</span></p></section><section id="sec2.4" style="margin: 0px 0px 8px; padding: 0px;"><h3 id="sectitle0045" class="u-h4 u-margin-m-top u-margin-xs-bottom" style="margin-right: 0px; margin-left: 0px; padding: 0px; color: rgb(80, 80, 80); margin-top: 24px !important; margin-bottom: 8px !important; font-size: 1rem !important; line-height: 1.4 !important;"><span style="font-family: Helvetica; font-size: 14px;"><b>Ethical considerations</b></span></h3><p id="p0085" style="margin-bottom: 16px; padding: 0px;"><span style="font-family: Helvetica; font-size: 14px;">The study received ethical approval from the Royal Children's Hospital Ethics Committee (reference number HREC59840).</span></p><h2 id="sectitle0050" class="u-h3 u-margin-l-top u-margin-xs-bottom" style="margin-right: 0px; margin-left: 0px; padding: 0px; color: rgb(80, 80, 80); font-family: NexusSerif, Georgia, &quot;Times New Roman&quot;, Times, STIXGeneral, &quot;Cambria Math&quot;, &quot;Lucida Sans Unicode&quot;, &quot;Microsoft Sans Serif&quot;, &quot;Segoe UI Symbol&quot;, &quot;Arial Unicode MS&quot;, serif; margin-top: 32px !important; margin-bottom: 8px !important; font-size: 1.2rem !important; line-height: 1.333 !important;"><b><span style="font-family: Helvetica; font-size: 14px;">Results:</span></b></h2><h2 id="sectitle0050" class="u-h3 u-margin-l-top u-margin-xs-bottom" style="margin-right: 0px; margin-left: 0px; padding: 0px; color: rgb(80, 80, 80); font-family: NexusSerif, Georgia, &quot;Times New Roman&quot;, Times, STIXGeneral, &quot;Cambria Math&quot;, &quot;Lucida Sans Unicode&quot;, &quot;Microsoft Sans Serif&quot;, &quot;Segoe UI Symbol&quot;, &quot;Arial Unicode MS&quot;, serif; margin-top: 32px !important; margin-bottom: 8px !important; font-size: 1.2rem !important; line-height: 1.333 !important;"><img src="/media/django-summernote/2022-11-16/548dce0b-cb59-4e7c-9fc3-031cc44ea8fa.png" style="width: 100%;"><span style="font-family: Helvetica; font-size: 12px;">&nbsp;(</span><span style="color: rgb(46, 46, 46); font-size: 12px; font-family: Helvetica;">Key themes and subthemes related to the routine vaccination experience of autistic children and their families.)</span><b><span style="font-family: Helvetica; font-size: 14px;"><br></span></b></h2></section></section>