Table 2.

Key themes from semi-structured interviews

Theme	Country	Role
Centralized immunization framework and political commitment	Italy	Centralization of immunization activities allied with supportive political commitment has benefits over the previously fragmented and often unfocused approach seen with decentralized delivery Setting national immunization targets with appropriate measures for regional delivery has improved vaccine uptake Streamlined engagement of local politicians can prevent delays in outbreak response (as evident in COVID-19 responses) New policy introduction is heavily influenced by political factors; greater engagement with politicians is essential to support policy decision-making Policy decisions can seem complex; public debate on complex policy decisions (and disagreements between political and health-care stakeholders) can have a negative impact on public perception
	UK	Cost-effectiveness seems a key driver of health-care decision-making; systematic defunding of services Disconnection between the political narrative and subsequent actions; perception of competing interests Political factors can impede expert led/evidence-driven public health recommendations; greater engagement with politicians is essential to support policy decision-making Policy decisions can seem complex; public debate on complex policy decisions (and disagreements between political and health-care stakeholders) can have a negative impact on public perception
Top-down vs bottom-up implementation and equity	Italy and UK	Need for closer public/community engagement to inform and address existing trust issues; underserved communities may have specific needs Public-involvement in policy-development and implementation remains limited; public attitudes toward immunization are complex and often divisive While the antivaccine movement may seem marginal, it may represent deeper societal roots; perceived disenfranchisement contributes to mistrust and skepticism toward public health measures (including immunization)
Incentives to vaccinate and mandatory vaccination	Italy	Mandatory immunization considered a successful policy development with a positive societal impact Political commitment considered a key facilitator
	UK	Limited appetite for mandatory vaccination (political or health-care experts) Potential benefit is countered by reduced public trust in health-care system; concerns exist that policy will not address unmet needs of vulnerable populations
Vaccine hesitancy as a symptom of declining trust	Italy and UK	Vaccine hesitancy reflects broader societal views; perception of unmet needs and/or individual disenfranchisement (especially in UK) Lack of community engagement negatively impacts new policy implementation
Education	Italy and UK	Public education is the key action to improve vaccine acceptance and uptake Ideal opportunities include prenatal and school-based education to inform parents and future adults on preventive healthcare (including immunization)
Impact of COVID-19 on immunization attitudes	Italy and UK	Provides an opportunity to refocus public health activities; currently, COVID-19 has increased trust in health-care systems (in the short term) In Italy this may reinforce the top-down approach to disease prevention policies In the UK the long-term impact is uncertain; based on previous experience, positive political and public attitudes may be transient