https://orcid.org/0000-0002-9537-7788
ABSTRACT
Children’s vaccination is a major goal in health-care systems worldwide; nevertheless, disparities in vaccination coverage expose socio-demographic accessibility gaps, unawareness, physicians’ disapproval and parents’ incomplete adherence reflecting insufficient public-provider trust. Our goal was to analyze parents’ attitude toward children’s vaccination in correlation with trust among stakeholders. A total of 1031 parents replied to a “snowball” questionnaire; 72% reported high trust in their physician, 42% trusted the authorities, 11% trusted internet groups. Among minorities, parents who fully vaccinate their children were younger, live in urban areas, eat all kinds of foods and trust the authorities, similar to the general population. Low adherence to children’s vaccination was correlated with trusting internet groups. Females complied significantly more to child vaccination, although in our study mothers were more highly educated and trusted authorities more than males. The results enable to draw a profile of the “vaccination compliant parent” (with an academic degree, young, urban, eats all kinds of foods, uses conservative medicine). Trust is a major factor influencing vaccination, yet external forces such as community voices, social trends and opinions of religious leaders may play a role in vaccination adherence, beyond personal beliefs, individual habits and self-care. In Israel, education and “healthy behavior” perception alongside generous coverage encourage most parents to comply with the routine vaccination program. In the shade of pandemic outbreaks, we suggest a social-determinant transparent approach to encourage parents to vaccinate their children. Social and religious leaders can pose as agents of change, especially in the case of less educated parents.
Introduction
Children’s vaccination is one of the major goals of advanced health-care systems worldwide, to facilitate public health and ensure better health outcomes for their citizens. Israel achieved 98% compliance,Citation1,,Citation2 similar to Sweden, Germany, Spain, Japan (96–99%), and higher than Australia, New-Zealand, Canada (91–94%), or India (85%).Citation3 We specifically focused on a comparison to OECD countries presenting the highest vaccination rates from the most updated international database available. A measles outbreak in 2019 revealed lack of vaccination in areas correlated with socio-demographic subgroups, disapproving preventive medicine. Public internet discussions hosted doubt about vaccination effectiveness versus risk, criticizing health authorities’ accountability, correlating compliance to vaccination to public-provider trust.
While vaccination is a successful public health intervention, a parallel movement against vaccines exists in many countries varying by extent – 9%–41%Citation4 and race.Citation5 Hesitance or refusal to vaccinate is a global concern,Citation6 triggered by three approaches: contextual, individual/group acceptance, and vaccine-specific.Citation7 In India the increasing hesitance seeds from skepticism toward medical technology, lack of transparency, conflicts of interest with vaccine policy, alternative healing concepts and influential social media.Citation8 Other barriers are poor quality health services, inaccessibilityCitation8 or unaffordability.Citation9
Personal factors – experiences, emotions, risk perceptions, influential peers or relatives shape parental vaccination decision,Citation10,Citation11 both in highCitation10 and lowCitation11 income countries.Citation12
On provider-individual encounter spectrum, three dimensions of “trust” are identified: the authorities (policy, funding), the physician as the professional delegate, and the nonprofessional agent – family members, peers and social network/media. Hence, we will discuss these three dimensions.
Trust in the authorities plays a role in parents’ compliance to vaccinate their children. In Italy, 19% of parents believed that vaccines were harmful and 10% did not have trust in the scientific community in regards to vaccines.Citation13
Immigrants express lower trust in the national vaccination policy and in their providers (health professionals), while facing both a new health system, and uncertainty toward the risk of unique vaccines (HPV),Citation14 in addition to cultural diversity, language and communication barriers.
Parental decisions embody trust in physician advice,Citation15 based on society’s health values, own beliefs and preferences. Parents who consulted pediatricians were less hesitant than parents who consulted general practitioners. Homeopathists’ consultation correlated with the highest hesitancy.Citation4 Beyond patient-provider dialogue, vaccination compliance is in accordance with social-ethical values: freedom of choice, autonomy and responsibility for one’s health – all components of patient- centered care.Citation16,Citation17
In the era of transparent mass information, social media may strongly influence vaccination hesitancy. Misinformation may increase uncertainty, cause confusion and even assimilate vaccination resistance.Citation18 A peak of YouTube films quoting the link between vaccines and autism in 2016 correlated with low compliance to children’s vaccination during 2017. The Internet may fuel controversial issues, nevertheless, it may also provide new tools to fight against vaccine hesitancyCitation19 track lay-people’s perceptions in real time, to actively engage citizens ad hocCitation20 .
Vaccination decisions sometimes evolve parallel to accumulative information, or diffusion of negative information online,Citation21 thus an overall trust in the pediatrician is crucial.Citation22,Citation23
To capture public trust and raise knowledge, the awareness and confidence concerning vaccines proved to be successful interventions, especially by targeting low- and middle-income regionsCitation23 and approaching the paucity of information directly to vaccination-hesitant individuals.Citation24
Our aim was to analyze parents’ attitudes toward vaccinating their children in correlation with trust in 3 stakeholders: the Ministry of Health (MoH) (the authority), the physician and social networks.
Methods
The survey was conducted from January to April 2018. The authors distributed the questionnaire through public social network groups, having interest in children’s vaccinations, including parents’ net-discussions regarding vaccination hesitance throughout the country, as well as addressing their peers and colleagues.
A structured questionnaire was scrutinized via e-mail in a “snowball” methodology, meaning that the participants were asked to reply and further disseminate the questionnaire to peers and relatives.
The questionnaire included children’s vaccination status, engagement in health promotion or screening tests, general behavioral perception (type of diet, utility of alternative medicine) and demographic details.
“Lifestyle” was defined by the composition of the type of social community (rural versus urban) and type of diet (vegan versus all kinds of food).
Full vaccination status was defined by the Israeli national recommended children’s vaccination program for four vaccines: MMRV, Hepatitis A, Hepatitis B and DTaP+IPV+Hib, as published on the MoH site: https://www.health.gov.il/Subjects/pregnancy/Childbirth/Vaccination_of_infants/Pages/default.aspx. available 14/6/2021].
The Arab population was defined by culture, including Muslim and Christian subpopulation.
We present means, standard deviations or numbers (N’s) and percentage of vaccinations by levels of possible explanatory variables for all populations in general and for the Arab population in particular.
We used Chi-squared analyses for univariate analyses of the vaccination variable. We used uni-variable and multi-variable logistic regression to examine the influence of trust in the 3 healthcare actors, gender, age, religion (culture), religiosity, family status, educational level, type of social community, number of children, children with special needs, use of alternative medicine, type of diet and conducting screening tests such as: height weight follow-up, development follow-up, doctor follow-up, fecal occult blood, mammography, newborn hearing screening test and routine physical examinations at school. We present the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) and p-values.
We used linear regression to examine what variables influence the expressed trust in the MoH and the trust in the internet groups.
The analyses were conducted using the statistical programs R 3.6.2 and SPSS Version 25.
Results
A total of 1031 responders replied; 20 non-parent responders were excluded, and one participant who did not complete the whole questionnaire; 1010 questionnaires were analyzed.
Most of the responders were females (80.9%) Jewish (94.0%), with academic degrees (83.6%), married or in relationships (94.1%) and live in urban areas (70.6%); 53.3% were non-religious (secular), 30.3% declared to be religious (11.5% were traditional and 4.9% orthodox). The responders had on average of 2.6 children and their mean age was 37.7 years. Most of the responders eat all kinds of food (88.0%). About 49.3% of the responders use alternative medicine; 81.3% of the responders reported they vaccinate all their children according to the full recommended national program, 15.1% engaged in a partial vaccination program and only 3.6% didn’t vaccinate any of their children.
“Healthy behavior” was assessed by engagement in health promotion or screening activities: most of the responders conduct routine physical examination (height and weight) follow-up for their children, developmental follow-up (91%) and pediatrician surveillance (83.5%). Most of the parents also regularly conduct self-screening tests (fecal occult blood 83.8%, mammography 89.1%), or have their children screened for newborn hearing test (89.5%) routine public health examination by a school nurse (83.9%).
Vaccination and trust
We investigated the correlation between child vaccination and trust among three major players: the MoH, the personal physician and the influence of peers’ recommendations through the net. The results showed that 41.8% of the responders reported that they fully trust the MoH. The others reported 44.0% partial trust, while 14.3% have no trust in authorities. Almost ¾ trusted their physician (fully trust 72.4%, partial 23.5%, don’t trust 4.2%). Full trust in internet groups was reported by only 10.5% of the responders, while 41.7% don’t trust and 47.8% only partially trust peers on the net.
We revealed a correlation between vaccination and trust in the MoH and the doctor (p < .001). Parents who fully vaccinate their children tend to trust the MoH and the doctor, while parents who don’t vaccinate their children or partially vaccinate tend not to believe direct messages announced by the MoH and the doctor. Significant correlation was found between children’s vaccination and the perception of child preventive medicine as expressed in conducting pediatric screening examinations: height and weight follow-up (p < .001), developmental follow-up (p < .001), standard pediatrician surveillance (p < .001) and newborn hearing screening test (p = .008). Self-preventive medicine was not significantly correlated with vaccination (fecal occult blood (p = .63), mammography (p = .84), no association was found between routine school nurse examination and vaccination (p = .140)) ().
Table 1. Demographics N (%) or mean (SD) by vaccination
Table 2. Vaccination status (full, partial, no) of study participants, by screening opinions and trusting variables. n (%)
Focusing on the Arab minority, vaccination was correlated with trust in the MoH (p = .025) (as in the general population) but also trust in the internet group (p = .013) (unlike the general population). However, this correlation was not consistent: Arab parents who fully vaccinate their children tend to trust the MoH and not internet groups, while parents who don’t vaccinate their children or partially vaccine, tend not to trust the MoH, but fully or partially trust internet groups ().
Social influence on vaccination decisions or relying on peers is associated with the level of education (p = .0183). Parents with academic degrees tend to trust the networks less than non-academic parents. Parents with only one child significantly trust the networks more than parents with more than one child (p = .004). Younger parents trust the networks less than older parents (p = .030).
Adherence to vaccination and personal characteristics
When comparing the level of adherence to child vaccination (parents fully vaccinate, partly vaccinate or don’t vaccinate their children, ), high adherence was significantly correlated with an academic degree (p = .002). Younger age was associated with high adherence to vaccination (p < .001), as parents age increased, adherence was appeared to decrease. These trends of compliance to vaccination are similar to trust trends. Adherence to vaccination also correlated with the type of diet (p = .049) and utility of alternative medicine (p < .001): full adherence was correlated with parents who eat all kinds of foods, while vegetarians correlated with partial vaccination and vegan with a tendency not to vaccine their children. Similarly, parents who use conservative medicine fully vaccinated their children (86.5%) while parents who tend to use alternative medicine only partially vaccinate or refused to do so. Analyzing the sub-population with high hesitance by religion revealed, Jewish parents reported partial compliance, while Arab parents reported mostly noncompliance (p = .001).
Focusing on the Arabic minority (~6% of the study population) three factors regarding adherence to child vaccination were observed, showing significant differences compared to the general study population: parents’ age (p = .019), as the parents’ age increased, adherence decreased. Regarding the type of social community (urban/rural) (p = .012), full adherence was correlated with urban living style, while partial or no adherence was associated with living in rural areas and villages. On the issue of the type of diet (p < .001): parents who eat all kinds of food fully vaccinated their children, while vegan parents reported partial adherence and vegetarians tended to avoid vaccines ().
Univariate analyses of the vaccination adherence status (fully vaccinated vs. not or partial) showed that education, age, preference of conservative medicine, level of trust in the medical authorities (the MoH and the doctor) and compliance with other child screening examinations, are all parameters that were associated with the agreement to the benefits of vaccination and an acceptance of the national vaccination program.Younger parents, with academic degrees, who don’t use alternative medicine, trust the MoH or the doctor, and conduct screening tests to all their children, had less risk of not vaccinating their child (). The multivariable model () confirms our findings for most of the variables from the univariate analyses. Vaccination remained significantly associated with age (p < .001, OR = −0.01), low utility of alternative medicine (p < .001, OR = −0.08 Yes vs. No), trust in the MoH (p = .003, OR = 0.07 partial vs. don’t trust, OR = 0.13 trust vs. don’t trust), height and weight follow-up (p = .004, OR = −0.25 some of the children vs. all children), doctor’s follow-up (p = .011, OR = −0.03 some of the children vs. all the children and OR = −0.23 no-one vs. all the children) and newborn hearing screening test (p = .012, OR = 0.23 partial vs. don’t trust and OR = 0.3 trust vs. don’t trust). Women were significantly more adherent to child vaccination (p = .030, OR = 0.06 vs. man). Education, trusting the doctor and developmental follow-up were no longer significant. This can be explained by the fact that gender, trusting the doctor and conducting developmental follow-up were significantly associated with alternative medicine and education. Women were more highly educated than men (p = .015) and use more alternative medicine (p < .001). Parents who take their children to developmental follow-up tend to be more educated (p = .002) and don’t use alternative medicine (p < .001). Parents who don’t trust the doctor tend to be less educated (p = .001) and use alternative medicine (p = .027). To better understand the significance of trust among different players, an additional analysis is presented in . We revealed that older, less educated parents at first parental status showed higher trust in internet groups, while younger parents have a significantly higher trust in the MoH. The multivariable model () confirms all our findings of the univariate analyses. Trust in the internet group remained significantly associated with age (p = .032, OR = 0.02), education (p = .044, OR = −0.36 non-academic education vs. academic degree) and first child (p = .005, OR = 0.43 yes vs. no), whereas age is the only significant variable that was found associated with trust in the MOH (p < .001, OR = −0.03) ().
Table 3. Univariable and multivariable statistical model results for vaccination. Vaccination yes vs. not or partial
Table 4. Univariable and multivariable statistical model results for trusting the ministry of health and trusting internet groups
Discussion
Vaccination is one of the most beneficial health activities that governments supply to large populations, yet regulators struggle for an effective mechanism.Citation25 The lack of vaccines and insufficient therapeutics for a worldwide pandemic outbreak of COVID-19 during 2020, was a robust facilitator to encourage vaccination,Citation26,Citation27 although routine children’s vaccination may be postponed as a result of fear of a pandemic, specifically during the Corona virus outbreak.Citation28,Citation29
Israel achieved a high percentage of national adherence to routine children’s vaccination, among the highest worldwide (98% in 2015) compared to the OECD average (95%).Citation2 The percentage in our study population was lower (81.3%), as we specifically tackled targeted noncompliant subpopulations, and even parents with resistance to vaccination, such as minorities and supra-orthodox groups who don’t conform to health authorities.
Socio-medical beliefs alongside fake information about vaccination harm appear from time to time.Citation30,Citation31 They happen to have more influence on populations who have fragile trust in health promotion programs. We conducted this study following unexpected polio and measles outbreaks, which raised the need to assess parents’ adherence to child vaccination.Citation32 Public internet discussions enlightened parents questioning the advantages of vaccines versus possible complications, and highlighting the gap in sufficient dialogue between the MoH and the public.Citation33
Several actors may be involved in this arena, other than the regulator (MoH) and health professionals. These include the insurer, the payer, other caregivers and the media, together with peers and family members. We revealed that even in the population, which was fully compliant with vaccination, parents reported only partial trust in the authorities. During 2009, the willingness of the public to take part in the preparedness efforts to gas masks acquisition campaign was only modest (35.6% of respondents), yet the response to H1N1 vaccination campaign was even lower (8.8%). This decreased compliance was accompanied by significant controversy, as it depends on the trust that the population has in authorities.Citation34 Parents’ trust in their physician was relatively high, while their trust in peers through net communication was minimal. Parents who did not vaccinate their children showed the opposite point of view: higher trust in internet groups compared to low trust in the MoH and very low trust in the physician. Overall, the “profile” of parents who trusted the network was: older parents, with non-academic degree, and having only one child. Lack of basic knowledge, professional guidance and experience may explain why these parents seek answers in the internet.
We assume that parents who don’t comply with vaccination, reflect low trust in doctors or the MoH as “medical agents,” and rely on personal beliefs and lifestyle preferences, and the support of their “community,” who may share the same suspicions regarding the benefits of vaccination. Parents’ vaccine hesitation may occur due to both internal doubt and reluctance and external influence not only of peers, but even expressed by experts who struggle with the dilemma of vaccination benefit versus risk.
Indeed, health professionals play an important role in vaccination adherence, such as in the case of measles vaccination.Citation35 In France, a trusted physician engaged parents to the vaccination program, while governmental bodies and network discussions were less influential. Resistance to children’s Influenza vaccination in Israel was reported by both Jewish (27.5%) and by Arab parents (37.5%).Citation36 The insurer (HMO) influence was stronger among minorities: 22% versus 5% in Arabic and Jewish parents, respectively. Knowledge about the severity of winter influenza persuaded 65% of Jewish and 49% of Arab parents, along with information provided by medical professionals (21% in both subgroups).Citation36
Family members can create an atmosphere for the need to protect young children. Grandparents may often encourage young parents to vaccinate their children, as they were exposed to extensive worldwide immunization campaigns in the 1960’s. Moreover, older people more generally, promote vaccination uptake.Citation37
Our study revealed that personal characteristics strongly affect vaccination adherence: older parents who have more than one child tend to be more compliant to vaccination, maybe due to their good experience, while younger parents may be more anxious; educated parents are more compliant as they understand vaccinations’ benefits.Citation38 However, during COVID-19 vaccination, parents with lower education were more willing to enroll in a vaccine trail.Citation39
Analyzing the minority Arabic subpopulation, younger parents who live in urban communities have higher adherence to child vaccination compared to older Arabic parents who live in rural communities. We assume cultural modernity penetrated and influenced to a better realization of the advantages of vaccines in this minority subpopulation. Others speculate that in the Arab population traditional conservative lifestyle is less supportive of skepticism and personal preferences.Citation40
Lifestyle was significantly correlated with children’s vaccination in our study: parents who don’t or partially vaccine their children tend to be vegan or vegetarian, and use alternative medicine, while parents who fully vaccinate tend to eat all kinds of food, and don’t use alternative medicine.
Expanding the scope toward health promotion and child preventive medicine, conducting pediatric screening examinations was significantly correlated to child vaccination. Interestingly, self-preventive medicine (fecal occult blood and mammography) was not significantly correlated neither in the general population’ nor in the Arab population.
The literature revealed that parents with a higher socioeconomic status (SES) were better engaged, and displayed greater health literacy,Citation41 which may expand their understanding about the benefits of vaccination, although SES is not a direct predictor. Moreover, the lowest vaccination uptake was reported in municipalities with greater income inequality (wider SES gaps), thus specifically designed efforts to approach gaps in income diversity is recommended.Citation42 Although vaccines are often cost saving, funding may influence strategies.Citation43 In developing countries financial barriers to vaccination exist, thus subsidizing mandatory and recommended vaccines may increase adherence.Citation44 In Israel, as in other countries with wide coverage for children vaccination, funding is not a barrier.Citation45
A thorough understanding of parents’ attitudes and incentives is crucial to build trust in the health ecosystem. This is a major challenge, since influential forces strike in social media, and are not readily accessible to medical authorities. In a previous study, we analyzed 200 online network discussions debating on an emergency poliovirus vaccination campaign in Israel in 2013. The social “market” framework encompassing the activity of three parties: authoritative agents (exhibiting professionalism) promoting vaccinations, alternative agents spreading doubts and negative emotions of distrust and fear, and the general public, the customers – deliberating whether to comply with vaccination.Citation46
The individual is the key player; therefore, authorities should wisely address the parent for the engagement of healthy behavior. Vaccine hesitancy reflects a broad spectrum of feelings and thoughts dealing with complex dilemmas, involving autonomy, doing “good” (beneficence) and accountability. Addressing vaccine hesitancy is challenging, but ultimately fruitful.Citation47
Healthcare leaders should consider two parallel pathways: the first, holding a wise dialogue with parents. Secondly, the approach of “one size fits all” must be reconsidered to relate to local ethnically diverse, deprived populations and individual differences, such as age/generation concepts. An adjusted approach by text-message reminders to younger parents may be motivated.Citation48 Considering involving religious or opinion leaders may encourage the uptake of vaccinations in their communities. A community-based intervention with multiple stakeholders and addressing psychosocial of hesitancy due to lack of knowledge, may help policymakers to design more targeted vaccination campaigns.Citation13
Even if objection to vaccination is individual, based on personal doubts, it is often related to group concepts. For instance, the objection to influenza vaccination exists even among healthcare professionals and may infiltrate, affecting their own behavior against our expectationsCitation48.Positive physician’s attitudes toward vaccination enhancing trust in authorities, may encourage children’s vaccine uptake.Citation49
We believe that not only trust is a major incentive to children’s vaccination adherence, but also the impact of the whole community may also play a role in vaccination adherence beyond individual/self-care, being a platform to improve public health and accountability for the “tribe.” The Arab minority subpopulation are less compliant with preventive medicine,Citation50,Citation51 therefore intensive national efforts targeted to this group are required. In our study, although their share among responders was smaller compared to their part in the general population (6% vs. 21%), two major trends were identified: personal characteristics (age and education) and the pattern of lifestyle (type of social community and the type of diet) reflecting tradition, habits and social preferences which strongly affect adherence to child vaccination. Positive interaction with cultural leaders may inspire trust in the benefit of vaccination.
Education for healthy behavior alongside generous coverage, encourage most parents in Israel, and in other countries, to vaccinate their children, following the routine recommended vaccination program. Healthcare professionals played an important role in the uptake of the measles vaccination through establishing trusting relationships with parents.Citation34 The current lack of knowledge concerning how immune responses to vaccines are generated is a critical barrier to understanding poor vaccine responses, thus explanations given by medical professional are crucial. Health authorities may intensify their approach to young mothers to initiate vaccination. The opinion of religious leaders influences social trends and personal beliefs.Citation52 Therefore, we suggest addressing these leaders as agents of change especially focusing on less educated, poor and minority populations. Although traditionally health is the mother’s role, social changes may call for the encouragement of fathers to also be accountable for preventive medicine related personally to their family. In the United Arab Emirates it was found that fathers and divorced status were significantly more vaccine-hesitant factors.Citation53 Thus vast cultural changes may be required to accomplish awareness among different societies, especially among parents who turn to alternative doctors. In Israel, there is open-mindedness toward a broad range of cultures and life styles. This finding in our population requires a thorough investigation as to whether the refrainment from children’s vaccination stems from lack of trust in authorities or a personal perception rejecting conventional medical intervention. In other countries innovative solutions to engage parents to vaccinate children were suggested: tailored vaccination programsCitation43 or “Personalized vaccinology”Citation54 (personal adoption of the vaccine to specific populations such as the elderly or children, and even to individual (immunologic and other) characteristics).Citation54 Using the internet as a tool for communication between the public and authorities was recently suggested.Citation55 These solutions may pave the way to a better understanding and compliance.
Limitations
The study was conducted during winter 2018 presenting a “snapshot” of the vaccination adherence attitude. A longer perspective is required, especially in the shade of Covid 19 vaccination programs.
The questionnaire diffusion methodology was a snowball methodology, thus the responders’ population may be biased. Moreover, we specifically targeted parents’ deliberation groups that argued benefits or discussed hesitancy to vaccination in the internet, to reveal their arguments.
Conclusions
Trust is a major incentive for children’s vaccination. Parent-physician relations are the most significant factor in compliance to children’s vaccinations, more than trust in the authorities and far beyond the influence of internet discussions. In Israel familial and community adherence may also play a role in vaccination compliance especially among minorities. Thus cultural leaders may be key players.
The results enable us to draw a profile of the “vaccination complaint parent” (with an academic degree, young aged, eats all kinds of food, tends to use conservative medicine, and urban) versus a less compliant population (with non-academic degrees, relatively older, vegan and relies on alternative medicine and rural, if they belong to a minority group).
Disclosure of potential conflicts of interest
No potential conflict of interest was reported by the author(s).
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