Elsevier

Vaccine

Volume 36, Issue 6, 1 February 2018, Pages 779-787
Vaccine

Parental vaccine hesitancy in Italy – Results from a national survey

https://doi.org/10.1016/j.vaccine.2017.12.074Get rights and content

Highlights

  • About 15% of Italian parents hesitate to vaccinate their children.

  • Safety concerns are the main reported reason for refusing or interrupting vaccination.

  • Negative or discordant advice from health professionals is associated with hesitancy.

  • Paediatricians are the main source of information on vaccinations for hesitant parents.

  • Multiple interventions are necessary to increase trust in vaccinations.

Abstract

In Italy, in 2016, we conducted a cross-sectional survey to estimate vaccine hesitancy and investigate its determinants among parents of children aged 16–36 months.

Data on parental attitudes and beliefs about vaccinations were collected through a questionnaire administered online or self-administered at pediatricians’ offices and nurseries. Parents were classified as pro-vaccine, vaccine-hesitant or anti-vaccine, according to self-reported tetanus and measles vaccination status of their child. Multivariable logistic regression was used to investigate factors associated with hesitancy.

A total of 3130 questionnaires were analysed: 83.7% of parents were pro-vaccine, 15.6% vaccine-hesitant and 0.7% anti-vaccine. Safety concerns are the main reported reason for refusing (38.1%) or interrupting (42.4%) vaccination. Anti-vaccine and hesitant parents are significantly more afraid than pro-vaccine parents of short-term (85.7 and 79.7% vs 60.4%) and long-term (95.2 and 72.3% vs 43.7%) vaccine adverse reactions. Most pro-vaccine and hesitant parents agree about the benefits of vaccinations. Family pediatricians are considered a reliable source of information by most pro-vaccine and hesitant parents (96.9 and 83.3% respectively), against 45% of anti-vaccine parents. The main factors associated with hesitancy were found to be: not having received from a paediatrician a recommendation to fully vaccinate their child [adjusted odds ratio (AOR): 3.21, 95% CI: 2.14–4.79], having received discordant opinions on vaccinations (AOR: 1.64, 95% CI: 1.11–2.43), having met parents of children who experienced serious adverse reactions (AOR: 1.49, 95% CI: 1.03–2.15), and mainly using non-traditional medical treatments (AOR: 2.05, 95% CI: 1.31–3.19).

Vaccine safety is perceived as a concern by all parents, although more so by hesitant and anti-vaccine parents. Similarly to pro-vaccine parents, hesitant parents consider vaccination an important prevention tool and trust their family pediatricians, suggesting that they could benefit from appropriate communication interventions. Training health professionals and providing homogenous information about vaccinations, in line with national recommendations, are crucial for responding to their concerns.

Introduction

The World Health Organization (WHO) describes vaccine hesitancy as the “delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence” (page 4163) [1]. This phenomenon is globally increasing in the general population [2], [3], [4], [5], [6].

Research has identified several factors associated with parental vaccine refusal and hesitancy [7], [8], [9]. In order to map these factors, the WHO SAGE Working Group classifies them under three categories: contextual (due to historical, socio-cultural, environmental, institutional, economic or political factors), individual and group (e.g. personal beliefs and attitudes about prevention or previous experiences with vaccinations), and vaccine/vaccination-specific (e.g. concerns about a new vaccine or formulation or about mode of administration or delivery) [1].

In 2013, staff from the WHO regional offices conducted interviews on reasons for vaccine hesitancy with immunization managers of thirteen countries, representing the six WHO Regions, confirming that causes of vaccine hesitancy varied in the different countries and also through-out the same country. This indicates a need to strengthen the capacity of countries to locally identify the relevant causal factors of vaccine hesitancy and to develop tailored strategies to address them [10].

In Italy, childhood vaccination coverage rates for various vaccine-preventable diseases have been decreasing since 2013. In 2016, the vaccination coverage rate for poliomyelitis in children at 24 months of age was below 95% [11]. This comes at a time when the WHO European Region is at risk for a poliomyelitis outbreak [12,13]. Moreover, in 2016, the vaccination coverage rate for measles in children at 24 months of age was only 87.3% [11] and a large measles epidemic occurred in Italy in 2017, with more than 4885 cases reported from January to December 2017 [14].

We carried out a cross-sectional survey to estimate the degree of parental vaccine hesitancy existing in Italy and investigate its determinants among parents of children aged 16–36 months.

Section snippets

Study population and data collection

The survey, coordinated by the Italian National Institute of Public Health (Istituto Superiore di Sanità), was conducted in the period December 2015 – June 2016, among parents of children aged 16–36 months. Data were collected: (i) through a Computer/Mobile Assisted Web Interviewing survey performed by an external research company that sampled participants from an online panel of Italian families, stratified to reflect the geographical distribution of the reference population by macro area

Results

A total of 3230 questionnaires were collected: 1924 (59.6%) from pediatricians and nurseries and 1306 (40.4%) from the online survey. Most questionnaires (72.5%) were completed by the mothers. One hundred questionnaires were excluded because of incomplete/missing information about tetanus and/or measles vaccinations, leaving 3130 questionnaires available for the analysis. Socio-demographic characteristics of the sample are presented in Table 1.

Discussion

In our sample the proportion of vaccine-hesitant parents was 16%, whereas less than 1% of parents are fully opposed to vaccinations; 39% of all the parents had had some doubts about vaccinating their children. These results are in agreement with two surveys carried out in Canada in 2014 and Australia in 2012, respectively. According to these surveys, 19% and 8% of parents, respectively, reported that their children were unimmunized or partially immunized and 40% and 52%, respectively, declared

Conclusions

Vaccine safety is perceived as a problem by all parents, although hesitant and anti-vaccine parents appear more concerned than pro-vaccine parents, as well as less favorable to using combined vaccines and to vaccine co-administration. Like pro-vaccine parents, vaccine-hesitant parents still consider vaccination an important prevention tool and trust family pediatricians, suggesting that appropriate communication and information interventions aimed at increasing trust in vaccination may improve

Acknowledgments

We wish to thank all those were involved in the survey for the active collaboration: coordinators of the Regions that participated in the project, health professionals working at the local level, operators of nursery schools and kindergartens and all the parents who filled in the questionnaire without whom the conduction of the study would not have been possible.

Funding

The study was conducted in the framework of the CCM project “Chi dovrebbe essere vaccinato e perchè: toolkit per la società in evoluzione” (fasc. ISS: j3b), funded by the Italian Ministry of Health.

Competing interests

The authors declare that they have no competing interest.

Authors’ contributions

CG designed the study, prepared the material, coordinated and monitored the study activities, analyzed the data, interpreted the results, drafted and edited the manuscript. MCR designed the study, prepared the material, interpreted the results and edited the manuscript. MF designed the study, analyzed the data, interpreted the results and edited the manuscript. AF designed the study, interpreted the results and edited the manuscript. AB, FD, MD and CR designed the study, interpreted the results

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  • Cited by (0)

    1

    Present address: Department of Infectious Diseases, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy.

    2

    Present address: Office 05, Communicable Diseases and International Prophylaxis, Directorate General Health Prevention, Ministry of Health, Via Ribotta 5, 00144 Rome, Italy.

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