INTRODUCTION
Declining vaccination rates and increasing hesitancy are a worldwide concern [1], despite the fact that the majority of parents in Europe believe that vaccinations for children are important. This was confirmed by a large-scale study in eighteen European countries [2]. However, some of these countries are exceptions compared to the rest of Europe, including Poland and Bulgaria, where a significant lack of vaccine confidence among parents was found [2].
Assessing parents’ attitudes toward vaccination in children in general, and whether to include the COVID-19 vaccine in the immunization program and make it obligatory in the children’s vaccination schedule, is an important and timely task [1]. A parent’s attitude toward vaccines can be seen as an individual’s tendency to agree with the medical consensus that approved vaccines are safe and beneficial, and disagree with false information regarding vaccines [3]. According to the theory of planned behavior [4], parental attitude, i.e. a positive or negative evaluation of a given behavior (in this case, vaccinating or not vaccinating the child), precedes the behavioral intention, which in turn is the direct antecedent of the action. Consistent with this theoretical prediction, parents’ attitudes towards preventive vaccinations was found to be a strong predictor of the parents’ intentions not to vaccinate their children [5, 6] and also parent’s vaccination behavior [7, 8]. Therefore, unfavorable evaluation of children’s vaccination by parents may lead to serious public health consequences manifesting as a low level of vaccination coverage and poor health status of the entire population [9].
Parental vaccine beliefs, attitude toward vaccinations, and vaccine hesitancy (a “delay in acceptance or refusal of vaccination despite availability of vaccination services” [10]) are largely determined by various individual and social factors, such as the age of parents (both mother and father) [11], the level of parents’ education and their financial situation [11, 12], as well as the number of children [11], and place of residence and the subjective perception of a long distance from the place of vaccination as a barrier [11]. In addition to the above factors, individualistic parenting practices may affect parents’ beliefs and attitudes toward child vaccinations [13, 14]. These practices were found to be particularly common in specific communities, which may be created by parents of children of a particular profile/type of school [15]. In such population clusters, parents who refuse to vaccinate their children begin to create a group of mutual support. By being part of this relatively homogeneous community, these parents are less exposed to criticism for refusing vaccinations, and the decision not to vaccinate seems safe and socially acceptable to them [15]. Vaccine-reluctant parents were also found to be prone to seeking support on social media using the Internet and mobile technologies, enabling communication through interactive dialogue [16, 17]. The Internet environment was also found to be the area where anti-vaccine organizations bring together young, educated parents, usually city dwellers who want to live in harmony with nature [18]. Reich [19], by analyzing online discussions and qualitative data during in-depth interviews with mothers who refuse some or all vaccines, found that mobilizing collective social capital in networks of vaccine-refusing mothers can provide powerful sources of social support for themselves.
The relationship between parents’ attitudes toward vaccinations and their health behaviors have being studied intensively, but the question of what factors significantly influence these attitudes remains open. Therefore, it is important to identify the most important sources of information about vaccines that affect parental attitudes towards vaccinations. This can be crucial, especially for effective vaccination promotion and public health protection. It can help better understand and address parental concerns, leading to higher vaccination rates and better population health.
Therefore, the aim of this preliminary study was to assess the relationship between the degree of trust in medical staff and professional information sources (available in books as well as online professional services) and attitudes to vaccines among parents of young children. This assessment took into consideration other factors that may be associated with this attitude: other sources of information about vaccines, sociodemographic factors (number of children, parents’ age, education, and type of professional work), the previous occurrence of vaccination side-effects among children after vaccination, and whether parents received information from medical staff about the possible type and method of vaccination.
MATERIAL AND METHODS
THE SAMPLE AND ORGANIZATION OF THE STUDY
The study was conducted among parents of children admitted to the Non-Public Health Care Center in Krakow (Poland). The study used the diagnostic survey me- thod, using the author’s questionnaire. Data were collected from July to October 2022. The study covered a group of 136 parents of children who met the following inclusion criteria: children born between 2018 and 2022, under the care of a primary health care doctor, i.e. having an active declaration of choice; having a vaccination schedule implemented only in Poland, without supplementing it outside the country in any way; healthy children, without chronic diseases, such as cardiovascular diseases, chronic respiratory diseases, diabetes, or cancer; children born at term, i.e. between 38 and 42 weeks of pregnancy, with normal body weight, above 2500 g; and children who obtained a minimum of 7 points on the Apgar scale.
Each parent was invited to take part in the study and asked to give written consent to participate in the study during a visit to the primary care physician’s office. The parent was then informed about the plan and purpose of the study and acquainted with its conditions. Recruitment for the study was carried out by: (1) preparing a list of children born in 2018-2022 declared to a primary care physician (N = 381), (2) reviewing medical documentation, i.e. discharge cards from the neonatal ward, health cards, immunization cards of these children, (3) selecting only those children who met the inclusion criteria in the research group (n = 297), (4) sending N = 143 invitations to the study to parents of children meeting the inclusion criteria who reported to the primary care physician’s clinic between July and October 2022, (5) collecting properly completed survey questionnaires (n = 136), which constituted the research group. The survey questionnaire was therefore completed by 95.1% of parents invited to the study.
DATA ANALYSIS
Parents’ attitudes towards vaccinations were examined using a self-constructed scale. For this purpose, based on the literature, specific statements relating to the topic of childhood vaccinations in general were selected for study. The set of these statements was selected so that none of their types (extremely positive and negative) were too numerous. Among the set of statements, we included one about COVID-19 vaccination, due to the fact that it is a relatively novel concept. It read as follows: “The COVID-19 vaccine should be included in the Protective Vaccination Program and be made mandatory in the children’s vaccination calendar”. Respondents were asked to respond to all statements, expressing not only their approval or disapproval of each statement, but also to indicate the degree to which they agreed with it on a 5-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, definitely agree). These answers were scored from –2 to +2 points, with unfavorable statements scaled accordingly (reverse scoring), so that a high total score on the scale means a positive attitude towards vaccinations. This type of variable (summarized total score) was then included in further statistical analyses (Supplementary material – the reliability analysis of the self-constructed scale).
The remaining questions of the author’s questionnaire included issues such as: previous occurrence of vaccination side-effects among children, sources of obtaining information related to vaccinations, along with the degree of trust in a given source, on the following scale: (1) I trust it to a small extent, (2) I trust it to a medium extent, (3) I trust it to a large extent, (4) it’s difficult to say. Additionally, data were collected on parents’ age, gender, education, place of residence, number of children, and type of work.
STATISTICAL ANALYSES
Testing for potential confounders was performed to evaluate whether the parents’ characteristics affect their attitude towards vaccinations (expressed as the total score). The association between categorical variables with two categories and parents’ attitude was assessed with Student’s t-test, whilst categorical variables with more than two categories and parents’ attitude towards vaccinations were examined with one-way ANOVA. Pearson’s correlations test was used to examine the relationship between parents’ attitude and parental age (in years).
The second stage of analysis was conducted to investigate whether the effect of the degree of trust toward medical staff and other sources of information about vaccines could explain parents’ attitude toward vaccination before and after controlling for confounders, such as the number of children, parents’ age, education, previous occurrence of vaccination side-effects among children, as well as the information provided (or not) to the parents by medical staff about the possibility, type and method of vaccination. Additionally, we included “type of work” as a confounder with the categories “White- collar worker”, “Blue-collar worker”, “Blue and white-collar worker”, “Unpaid work (taking care of a child or other family member)”, and “I do not work (pensioner, retired, unemployed)”, to understand the diverse socioeconomic backgrounds of the parents and their influence on vaccination attitudes. These analyses were done with simple and multiple linear regression models.
Standardized (b), unstandardized (b), and semi- partial (r) regression coefficients were reported. In order to compare the effects of degree of trust toward various information sources of multiple regression models, the standardized regression (b) coefficients were used, because b coefficients are expressed in units of standard deviations and can be successfully used to make comparisons between models [20].
The categorical variables with more than 2 levels were entered as dummy variables in multiple linear regression models. Multicollinearity of predictors in multivariate models was assessed using the tolerance factor, with values less than 0.1 considered to indicate serious collinearity problems [21]. The significance level was set at 0.05. A p-value of less than 0.05 was considered as statistically significant. Analyses were performed using the STATISTICA package (version 13.3 TIBCO, Poland).
The research was approved by Andrzej Frycz Modrze- wski Krakow University’s Bioethics Committee (KBKA/ 37/O/2022 of: July 14, 2022).
RESULTS
CHARACTERISTICS OF THE STUDY GROUP
A total of 136 respondents took part in the study, whose characteristics are presented in Table 1. The age range of respondents was from 21 to 46 years, and the average age was 34.4 years (SD = 5.34). Half of the parents had no more than two children (median = 2, Q1 = 1.0; Q3 = 2.0). The study participants were most often mothers (n = 120, 88%), followed by fathers, who constituted 11% of respondents (n = 15). Among the respondents, there was also one legal guardian (n = 1, 1%). The vast majority of respondents (n = 121, 89%) lived in cities, and 11% lived in villages (n = 15). The largest group consisted of people with higher education (n = 108, 79%). People working in white-collar jobs constituted the largest group of respondents (n = 82, 60%). Among the 136 respondents, 39% (n = 53) reported the occurrence of vaccination side-effects among children in the past, which most often manifested as fever, local reactions at the injection site, rash, chills, enlarged lymph nodes and diarrhea. 93% of the respondents (n = 126) confirmed that they had been informed by medical staff about the possibility, type, and method of vaccinating their child.
Of the above characteristics, only parental education was significantly associated with attitude towards vaccinations (p = 0.03, Table 1).
Degree of trust in various information sources about vaccinations
The largest percentage of parents (69.85%) reported a high level of trust in medical staff, which suggests that this is the most important source of information for parents in the context of vaccinations. The trust toward books and professional Internet sources were the next trustworthy (64.0% and 38.2%, respectively). However, other sources of information about vaccinations were not highly trusted according to parents. Only a small percentage of parents stated that the level of trust in family members and friends, unprofessional Internet sources (such as forums and social media), and traditional sources of information (radio and television) is high, being 19.1%, 5.2%, and 3.7%, respectively (Table 1).
PARENTS’ OPINIONS AND ATTITUDES TOWARDS VACCINATIONS
Parents’ opinions on individual statements regarding vaccinations were analyzed by the degree of declared trust in healthcare staff (high vs. low and medium) and presented as percentages of responses (Figure 1). Most people with low and medium levels of trust (87.3%) believed that vaccinations should be mandatory (sum of “strongly agree” and “agree” responses, i.e. % of positive responses). People with high levels of trust were more divided on this issue, but the majority (55.3%) still support mandatory vaccinations.
Regarding parents’ opinion on the safety of childhood vaccinations, those with a high level of confidence overwhelmingly (83.2%) believed that vaccinations were safe. While the responses of those with low and medium levels of confidence were mixed, the majority (52.6%) believed that vaccinations were safe. The analysis of opinions on the effectiveness of vaccinations against infectious diseases showed that people with a high level of trust overwhelmingly (94.7%) believed that vaccinations were effective and protected against diseases. In the group of people with lower and medium levels of trust, the majority (71.1%) believed that vaccinations were effective and protected against diseases, although there were more people who dis-agreed (13.2%).
Considering the opinion on the threat of infectious diseases to the health and life of children, both parents with high, low, and medium levels of trust overwhelmingly believed that infectious diseases still pose a threat to the health and life of children (97.9% and 84.2%, respectively). When asking parents about their opinion on including the COVID-19 vaccine in the compulsory childhood immunization program, the following responses were received: those with a high level of trust were divided, with the majority (39.0%) not supporting the proposal, while the majority (73.7%) of parents with low and medium levels of trust in staff did not support the mandatory inclusion of the COVID-19 vaccine in the compulsory childhood immunization program. Opinions were also asked about strengthening natural immunity in children instead of using vaccinations. A majority of parents with a high level of trust in the medical staff (69.5%) did not support this idea (the sum of the answers “I disagree” and “I strongly disagree”). Among parents with a low level of trust in the medical staff, only half of them (50.0%) did not support this idea. The opinion of parents on the toxicity of vaccines was also analyzed. Those with a high level of trust mostly (59.0%) disagreed with the statement that vaccines contain toxic substances. In the second group (parents with low and medium levels of trust in staff), opinions were more diverse, but almost half (44.7%) disagreed with the statement that vaccines contain toxic substances.
In terms of opinions on complications after vaccination, people with a high level of trust were divided, but the majority (50.5%) did not agree with the statement that vaccinations can cause serious complications. In contrast, among people with a low level of trust, opinions were quite diverse: a large proportion (36.9%) did not agree with the statement that vaccinations can cause serious complications, but a similar percentage of these people (36.8%) had the opposite opinion. In addition, 26.3% of people had no opinion on this subject.
Parents were also asked whether they believed that vaccinations only benefited large pharmaceutical companies. Those with high levels of trust in medical staff mostly disagreed with this statement (71.6%), while among those with low and medium levels of trust, opinions were more mixed, with almost half (47.4%) disagreeing with the above statement. The parents’ opinion on whether they believed that vaccinations were administered too early (on the first day after birth) was also analyzed. People with a high level of trust mostly (66.3%) disagreed with this statement. On the other hand, people with low and medium levels of trust mostly expressed the opposite view: almost half (47.4%) believed that vaccinations were administered too early. When analyzing the attitude of parents towards vaccinations, a summary total score was calculated. The total score ranged between –12.0 and 20.0, with the mean being 6.93 (SD = 6.41). The distribution of the summary total score among the respondents is visualized in Figure 2.
DEGREE OF TRUST IN VARIOUS INFORMATION SOURCES AND PARENTAL ATTITUDES TOWARDS VACCINATION
The simple regression models showed that the degree of parental trust in medical staff (p < 0.001), professional Internet sources (p < 0.001) and medical books (p = 0.03) had a significant positive effect on their attitudes towards vaccinations, while trust in other sources of information did not show a statistically significant effect (Table 2). Multiple regression analysis, after taking into account all the examined sources of information about vaccinations, showed that the greatest positive determinants of parental attitudes towards vaccination were: trust in medical staff (b = 0.44, 95% CI: 0.27-0.61) and trust in professional medical Internet sources (b = 0.30, 95% CI: 0.12-0.48). Parental trust in other sources of information did not affect their attitudes towards vaccinations. After taking into account all other confounding factors, the results remained the same (Table 2).
A higher adjusted R² in the model adjusted to various information sources (R² = 0.24) than in the full model (R² = 0.18) suggests that it better explains the variability in attitudes towards vaccination (despite a slightly higher RMSE), and therefore the further interpretations are based on this model. No problems with multicollinearity occurred among predictors in both multiple regression models.
Analyzing the semi-partial correlation coefficients in the multiple regression model, it was found that the trust in medical personnel explained the largest part of the variance in the parental attitudes towards vaccination (semi-partial r = 0.43), which cannot be explained by the influence of the remaining variables in the model. The professional Internet sources also showed a significant unique contribution to the elucidation of the variability of the dependent variable (semi-partial r = 0.27). Other sources of information did not show a significant unique contribution to explaining the variability of the parental attitudes towards vaccination. The comparison of parents’ attitudes towards vaccinations according to their degree of trust (low and medium vs. high) in medical staff and professional Internet sources of information, after taking into account confounding variables, is visualized in Figure 3.
DISCUSSION
We found that higher trust in medical staff (p < 0.001) and professional medical portals on the Internet (p = 0.002) was associated with a more positive attitude toward children’s vaccination. In this respect, our results are consistent with others. In a study based on in-depth interviews with Finnish parents who have refused all or several vaccines for their children, it was found that a loss of trust in medical and public health actors was central to the process in which parents came to question, contest, and eventually refuse childhood vaccination [22]. A recent study conducted in seventeen countries showed that trust in health care workers and scientists in general was a major factor influencing vaccine acceptance among parents in many populations [23]. And healthcare providers are considered to be the most trusted advisors and influencers of vaccination decisions, as was found in a study on six European countries [24].
Not only the decrease in trust in medical personnel, but also in healthcare institutions in general, may be related to parents’ refusal to vaccinate their children [25]. It was suspected that trust in science (medical research) influences attitudes toward vaccines, but this needs further examination [26]. It was emphasized that the loss of trust in medical research and medical staff, leading to hesitancy and refusal to vaccinate, can be seen as a social phenomenon of neoliberal parenting. The key aspects of this phenomenon included parents’ individualism and independence in making health decisions and responsibility for their own health and the well-being of their children [13]. Using interviews with 25 American mothers who refuse recommended vaccines, Reich [13] found that they were white, middle- to upper-class and claimed to have the right to make their own decisions about the care of their children. Reich [13] suggested that vaccine refusal is an elitist process in which mothers use their privilege to protect their children from public health standards. Individual decisions about children’s health are sometimes based on parental overconfidence. Interestingly, the highest levels of self-confidence were found among those with low levels of medical knowledge and those with high levels of endorsement of misinformation, as noted in a study of American adults [27]. These people were convinced that their own intuitions about family health decisions carry more weight than medical recommendations by authorities [27].
Another qualitative study highlighted the importance of parents’ empowerment in their engagement with vaccination [28]. Some respondents believed that “blind” trust in public health institutions was passive and risky, and “trust as faith” was negatively contrasted with empowerment. This empowerment was promised to result from taking personal responsibility for health and decision-making [28].
In addition, individual motivations for parents to take responsibility for their children’s health may stem from previous personal experiences with possible vaccine-related side effects, which may lead to questioning children’s vaccinations. Such a relationship was found for example in Finnish parents [22], which was related to the public discussion about narcolepsy cases associated with the H1N1 influenza vaccine (GlaxoSmithKline’s Pandemrix). This led to a lack of trust in vaccinations, which was reflected in reduced uptake of influenza vaccines in the years after the vaccine’s side effects were revealed [22]. A similar profile of parents who avoided vaccinations was found in a study in Poland [29]. There were parentally matured, mostly educated parents who had more than one child. In this group, more than half of the parents had experience in vaccinating previous children. The authors suggested that the combination of these features may indicate that parents who avoid vaccinations were people with strong views and well- established beliefs and have gained knowledge about the safety of vaccinations and the adverse events that accompany them. Our study did not support this phenomenon: we found that adverse effects after previous vaccination did not affect the current parental attitudes towards vaccination (p = 0.60).
Interesting answers were obtained when respondents were asked about their opinion regarding the inclusion of the COVID-19 vaccine in the vaccination program as a mandatory vaccination. Only 20% of parents were in favor of including this type of vaccination in the pool of compulsory vaccinations (the sum of the answers “I strongly agree” and “I agree”), and 31% of parents had an undecided attitude (the answer was “neither yes nor no”). The remaining 49% of the respondents (the sum of the responses “strongly disagree” and “disagree”) did not support this idea. These results are consistent with a study on a large sample of residents of England (over 1,200 people) described by Bell et al. [30]. The majority (90%) of participants there said they were likely to be more accepting of a COVID-19 vaccine for themselves than for their child(ren). Some studies showed that parents exhibit greater caution when deciding to vaccinate their children against COVID-19 compared to vaccinating themselves [31]. The reasons for this approach were primarily safety concerns: parents believed that the vaccine was prepared extremely quickly and therefore its effectiveness and side effects could not be noted [31, 32].
Our research, however, has some limitations. The most important one was the low representativeness of the sample resulting from the method of its selection: the study was carried out on a relatively small group of volunteers from one primary health care clinic. Extending the study to a larger number of respondents, randomly selected from all parents of children living in Krakow, using a computer-assisted web interview (CAWI), would probably significantly alleviate these limitations. Nevertheless, the method of collecting written questionnaires used in our own study allowed for interaction with the respondent and ongoing assessment of his competencies, i.e. whether he/she sufficiently understands the questions asked. In our study, a new tool was used to assess parental attitudes towards vaccination: a matrix of statements using a 5-point Likert scale. Reliability analysis (Supplementary material) showed a high Cronbach’s a equal to 0.87, which confirmed the high internal consistency of the test. An additional principal component analysis, which included all scale items (statements), showed that the matrix used to assess parents’ attitudes towards vaccinations is a homogeneous (unidimensional) scale and explains nearly 50% of the total variance.
Next, unfortunately, we did not take into consideration three important predictors of parental attitude. One of them is the general unwillingness to accept scientific evidence, as a potential predictor of negative attitudes to vaccines [33]. The evidence from large studies in the US suggested that conspiratorial thinking and political worldviews may have an impact on attitudes to vaccines [34, 35]. The second one was the predisposition to act with reactance in situations that are perceived as threats to the freedom of choice [36], which was another predictor of vaccine opposition [33]. Finally, we also did not take into account the level of trust toward alternative medicine, which can affect the level of trust in medical staff, and thus the parental attitude toward vaccinations. Parents with concerns about vaccination or who have not vaccinated their children appeared to trust non-mainstream sources of information, such as complementary medicine practitioners [37, 38] or homoeopathists [2].
Our research results should be treated with caution, because of the cross-sectional character of the study. For this reason, we are not sure whether trust in medical staff can be treated as a determinant of parents’ attitudes, or whether it is the other way around, i.e. whether parents’ attitude towards vaccinations of their children can be treated as a marker of trust in the health care system in general, as others suggest [39]. Although the survey first asked about trust in selected sources of information about childhood vaccinations (generally) and then included a question about the COVID-19 vaccine in a separate section, we recognize that including a statement about the COVID-19 vaccine in the section on attitudes may influence parents’ responses about their level of trust in sources of information about vaccinations in general. The results of the study can be considered from a practical point of view. Our study supports the idea of incorporating new strategies to address parental concerns about vaccinations and enhance communication between parents and healthcare providers. These efforts should focus on building trust in medical institutions and staff, ultimately leading to better adherence to vaccination schedules. Our findings also highlight the value of making efforts to minimize exposure to disinformation about vaccines on social media or online forums and ensuring access to professional sources of information about vaccines on the Internet. This is especially important when taking into account the increasing importance of new media in promoting pro-vaccination attitudes, especially when this source of information sometimes replaces a conversation with qualified health care staff [40]. It is worth mentioning that in the case of COVID-19 vaccinations, the Internet was often the main source of knowledge [41]. It is expected that not only beliefs about vaccinations may change over time under the influence of various communication roots, but so may the level of trust in medicine, medical professionals and authorities [42]. This will require constant monitoring and assessment of the acceptability of vaccinations among parents. Beliefs and attitudes toward vaccinations and trust in medicine may vary across social groups. In particular, people with lower levels of education and knowledge may be more susceptible to misinformation, which may affect their attitude toward vaccinations [43]. Our study did not support this: educational achievements did not affect the parental attitude toward vaccinations in children in the multivariate analyses (p = 0.38). However, future studies may focus on this issue and investigate the interaction between the level of trust in medical staff and parental education. This may be helpful in tailoring the communication strategies to different social groups in order to reduce health inequalities.
CONCLUSIONS
Our study highlights the significant role of trust in medical staff and professional medical portals on the Internet in shaping positive attitudes towards children’s vaccinations. The findings align with previous research, emphasizing the importance of reliable sources of information in promoting vaccination acceptance. The responses regarding the inclusion of the COVID-19 vaccine in the mandatory vaccination program revealed a divided opinion among parents. Only 20% supported its inclusion, while 31% were undecided, and 49% opposed it. These results are consistent with other studies, indicating that parents are generally more cautious about vaccinating their children against COVID-19 compared to themselves. Future research should continue to examine factors influencing parental attitudes toward vaccination, especially given newly emerging vaccines.
Disclosure
The authors declare no conflict of interest.
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