Elsevier

Vaccine

Volume 38, Issue 6, 5 February 2020, Pages 1505-1512
Vaccine

Vaccine confidence among parents: Large scale study in eighteen European countries

https://doi.org/10.1016/j.vaccine.2019.11.068Get rights and content

Abstract

Background

Despite the fact that vaccines save 2–3 million lives worldwide every year, a percentage of children are not getting appropriately vaccinated, thus leading to disease outbreaks. One of the major reasons of low vaccine uptake in Europe is vaccine hesitancy, contributing to the recent measles outbreaks. Monitoring of vaccine hesitancy is valuable in early identification of vaccine concerns.

Methods

We performed an eighteen country European survey on parents’ attitudes and behaviors regarding their children’s immunization. Parents having at least one child 1–4 years old were mostly recruited by primary care paediatricians to reply to a web-based questionnaire.

The questionnaire was developed by the European Academy of Paediatrics Research in Ambulatory Setting Network steering committee, based on similar surveys. An individual level hesitancy score was constructed using the answers to 21 questions, and correlations of the score with socio-demographic characteristics and types of providers were explored. To assess inter country differences, a country level self -reported confidence was defined.

Results

Fifty six percent and 24% of 5736 respondents defined themselves as “not at all hesitant”, and “somewhat hesitant”, respectively. Parents who consulted general practitioners were more hesitant than parents who consulted pediatricians (p < 0.05). Consultation with homeopathists was associated with the highest reported hesitancy (p < 0.05). Vaccine confidence was highest in Portugal and Cyprus, and lowest in Bulgaria and Poland.

Conclusion

The majority of parents in Europe believe in the importance of childhood vaccination. However, significant lack of confidence was found in certain European countries, highlighting the need for continuous monitoring, awareness and response plans. The possible influence of different types of healthcare providers on parental decisions demonstrated for the first time in our survey, calls for further research. Monitoring and continuous medical education efforts aimed mostly at those professionals who might not be likely to recommend vaccination are suggested.

Introduction

The World Health Organization (WHO) estimates that vaccination saves 2–3 million lives worldwide every year [1]. However, a percentage of children are not getting vaccinated leading to outbreaks even in developed and/or industrialized countries across Europe. WHO reported 88,692 measles cases in the European region in 2018 [2] (1st New reference) compared to 5273 cases in 2016 (2nd New reference) [3]. The majority of the cases were reported in Ukraine (53218), but high numbers of cases were also reported in Serbia (5076), France (2919), Italy (2686) and Greece (2193) [2] (1st New reference).

The main reasons of low vaccination coverage are access to health services, shortage of vaccines, health care profesionals’ attitudes and practices, parents’ knowledge on vaccination and vaccine hesitancy [4], [5]. A study on vaccine confidence in 2016 showed that vaccine skepticism was higher in Europe compared to the other continents [6]. While about a third of measles cases are probably non-preventable (too young to be vaccinated, measles despite being vaccinated twice), 63% were considered programmatically preventable in a recent review of global measles cases from 2013 to 2017 [7]. High skepticism regarding vaccination might contribute to the persistent European measles outbreak. The large outbreak of measles in Ukraine can be partially explained by parental vaccine safety anxieties but also by distrust in their government and by the fact that Ukraine’s health system needs to be reformed.

Unfortunately vaccine hesitancy is a global phenomenon and it has become a growing focus of attention and concern despite compelling scientific evidence of the value of vaccines in preventing disease and disability [8], [9], [10]. The following definition of vaccine hesitancy was developed by the WHO Strategic Advisory Group on Experts (SAGE) of Immunization [11]:

“Vaccine hesitancy refers to a 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”.

A high level of confidence in vaccines is an imperative factor for achieving high vaccination uptake. Vaccine confidence implies trust in the product and the company producing the product, trust in health authorities deciding on vaccine schedules, and trust in the health care professional providing or administrating the vaccine [12]. A recent study showed that confidence issues were the main drivers of hesitancy among parents [12].

Understanding the reasons of vaccine hesitancy is critical in developing appropriate interventions that aim to increase vaccine uptake. The WHO Strategic Advisory Group of Experts on Immunization has encouraged both researchers and health authorities to better monitor vaccine confidence and hesitancy, in order to develop strategies to address confidence gaps, to sustain confidence in vaccines and vaccination programmes and to stop the confidence crisis [13]. The questionnaire used for this study was based on two tools which have been developed to explore the attitude of parents in regard of vaccine hesitancy [14], [15].

There are three different primary care health systems in European countries [16]: Paediatrician lead system where all children are treated by paediatricians; general practitioner lead system where children are treated by general practitioners (GPs) and mixed system. Based on the type of health system, the information on vaccines to parents is given by paediatricians, GPs or nurses. Vaccine administration is not directly related to the system and can be performed by any of the three above health care professionals. According to this study [16] vaccinations were administered at the paediatrician’s office in eight countries, in the healthcare centre in nine and in multiple locations in twelve. Professionals involved in vaccination included nurses in five countries (Sweden, Portugal, Israel, Finland, Norway), paediatricians in five (Bulgaria, Czech Republic, Germany, Greece, Slovakia), GPs/FDs in five (Poland, Ireland, Estonia, Denmark, Belgium) and a combination of professionals in twelve countries.

To our knowledge, few studies have previously addressed the role of parental attitudes to vaccine uptake at a European level, the last one conducted in five European countries in 2008 [17].

The aim of this study is to assess parental behavior regarding immunization of their children, and to explore attitudes and beliefs regarding vaccine safety and efficacy in eighteen European countries.

Section snippets

Study population

The study population consisted of parents having at least one child 1 to 4 years of age, living in one of the participating eighteen European countries. Parents whose children were acutely ill at the time of the visit were excluded.

Sample size

Larson et al. [15] reported a lack of vaccine confidence varying from 1% in Germany to 10% in Romania to 18% in the Czech Republic. Assuming a lack of vaccine confidence of 10%, a sample size of 3557 produces a two-sided 95% confidence interval with a width equal to

Results

The response rate was higher than expected and we finally had 6070 responses from 18 countries. Three hundred and thirty-four responses were excluded because of incomplete data or misspelled codes, leaving 5736 responses available for the analysis. The number of analyzed responses and response rates from the participating countries is presented in Table 1.

The socio-demographic characteristics of the sample are presented in Table 2.

Discussion

In our sample of European parents, 20% have delayed and 12% have refused vaccinations; 24% defined themselves as somewhat hesitant and 4% as very hesitant. 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 having had concerns about vaccinating their child [25]

CRediT authorship contribution statement

Adamos Hadjipanayis: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Diego van Esso: Conceptualization, Data curation, Methodology, Writing - review & editing. Stefano del Torso: Conceptualization, Data curation, Methodology, Writing - review & editing. Hans Jürgen Dornbusch: Conceptualization, Data curation, Methodology,

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The authors would like to thank the EAPRASnet members for their dedication, commitment and for sharing with us their invaluable experience and precious time.

References (45)

  • J. Wardle et al.

    Complementary medicine and childhood immunisation: a critical review

    Vaccine

    (2016)
  • J.E. Frawley et al.

    The associations between medical, allied and complementary medicine practitioner visits and childhood vaccine uptake

    Vaccine

    (2018)
  • K. Attwell et al.

    “Do-it-yourself”: vaccine rejection and complementary and alternative medicine (CAM)

    Soc Sci Med

    (2018)
  • C.L. Kirkdale et al.

    Implementation of flu vaccination in community pharmacies: Understanding the barriers and enablers

    Ann Pharm Fr

    (2017)
  • World Health Organization. Assessment Report of the Global Vaccine Action Plan Strategic Advisory Group of Experts on...
  • WHO. Measles and rubella surveillance data. Jan 31, 2019....
  • Measles- European Region. Disease outbreak news – uptdate. 6 May 2019...
  • S. Black et al.

    A crisis of public confidence in vaccines

    Sci Transl Med

    (2010)
  • J. Leask

    Target the fence-sitters

    Nature

    (2011)
  • State of vaccine confidence in the EU 2018 available at:...
  • The SAGE Vaccine Hesitancy Working Group. Report of the SAGE working group on vaccine hesitancy. 2014;...
  • H.J.S.W. Larson et al.

    Measuring vaccine confidence: introducing a global vaccine confidence index

    PLOS Curr Outbreaks

    (2015)
  • Cited by (73)

    View all citing articles on Scopus
    View full text