Assessment of Vaccine Hesitancy among Parents of Children between 1 and 5 Years of Age at a Tertiary Care Hospital in Chennai.

Sir,

Immunization is considered as the most cost-effective and safest public health intervention to reduce childhood morbidity and mortality, although its full potential is not yet reached.[1] Every year, 5 lakh children die in India due to vaccine-preventable diseases, and another 89 lakhs remain at risk due to partial or no immunization.[2] According to the WHO, vaccine hesitancy refers to a delay in acceptance or refusal of vaccines despite the availability of vaccination services. Vaccine hesitancy reduces vaccine coverage. This poses particular problems in low- and middle-income countries with higher incidence of vaccine-preventable deaths. Several factors have been said to influence vaccine hesitancy, including sociocultural context, religious beliefs, misinformation spread through social media, historical influences and mistrust, beliefs and attitudes about vaccines, and specific characteristics of the vaccines.

The state of Tamil Nadu, which has some of the best health indicators in the country, has an interesting history of vaccination coverage. In the National Family Health Survey (NFHS) 1 (1992–1993), the coverage of all basic vaccines was about 65%, which increased to 89% in NFHS 2 (1998–1999). NFHS 3 (2005–2006) saw a vaccination coverage rate of 81%, a reduction over the coverage in NFHS 2 and the NFHS 4 (2015–2016) saw a further reduction to 69%. This trend of reducing vaccination coverage in a high-performing state is a matter of concern. One possible reason for the reduced vaccine uptake in Tamil Nadu could be vaccine hesitancy. A cross-sectional study was conducted in the pediatric outpatient department of a tertiary care hospital in Chennai, India. The participants included in the study were mothers of children between 1 and 5 years of age attending the pediatrics outpatient department of the tertiary care hospital. A sample size of 150 was arrived at to estimate a 40% prevalence of vaccine hesitancy with a 95% confidence and 20% relative precision. Participants who met this criterion were consecutively selected from the outpatient clinic in the period of June–July 2018. The study used a questionnaire which comprised three parts, namely – (1) sociodemographic details of the respondent, spouse, and child and (2) a scale to measure the vaccine hesitancy. The parental attitude toward child vaccines scale is a valid and reliable measure of parental attitudes and vaccine hesitancy.[3] This scale has not been previously validated for the Indian context. Therefore, the scale was validated by content validity method among experts in pediatrics and public health who evaluated the relevance of the scale in the Indian context and cultural and social appropriateness of the statements in the scale. The questionnaire was translated to Tamil, the local language and the validity of translation checked by an independent expert. The interviews were conducted by the lead author, a 2nd-year MBBS student as part of her research study. The study was approved by the Institutional Ethical Committee of the institution of origin of this study. Informed consent was obtained from all the participants before data collection. Adequate privacy was provided during the interviews, and the details of the participants were maintained in strict confidentiality.

Table 1 shows the responses of the parents to vaccine hesitancy questions. It is noteworthy that there is a tendency of suspicion toward newer vaccines that are introduced (61.4%), concerns about adverse events following vaccination (90.7%), and a feeling that vaccines are not necessary for diseases that are not common (85.3%). These responses indicate a sense of hesitancy of the sample and the main concerns for their hesitation. It is seen that about 5.3% of the sample had a high level of vaccine hesitancy. Table 2 shows the major factors influencing vaccine hesitancy. Backward conditional logistic regression analysis was performed with all the following factors included into the model – age of the mother, education of the mother, age of the father, education of the father, sex of the child, number of siblings, monthly family income, use of social media by mother, use of social media by father, and source of information regarding vaccines. It is seen that education of the mother protects against vaccine hesitancy (0.607; 95% confidence interval [CI] 0.406–0.907), whereas father's education increases it (1.438; 95% CI 1.007–2.055). Father's use of social media (23.255; 95% CI 1.355–333.333) and reliance on sources of information other than health-care providers (4.356; 95% CI 1.222–15.526) increases the risk of vaccine hesitancy.

Table 1

Responses to parental attitudes toward childhood vaccines scale

Statement	Strong agree (%)	Agree (%)	Neither agree nor disagree (%)	Disagree (%)	Strongly disagree (%)
Childhood vaccines are important for my child	65 (43.3)	84 (56)	1 (0.7)	0	0
Childhood vaccines are effective	18 (12)	131 (87.3)	1 (0.7)	0	0
Having my child vaccinated is important for the health of others in the community	7 (4.7)	113 (75.3)	19 (12.7)	11 (7.3)	0
All childhood vaccines offered by the government in my community are beneficial	8 (5.3)	128 (85.3)	10 (6.7)	4 (2.7)	0
Newer vaccines carry greater risks than older vaccines	43 (28.7)	49 (32.7)	27 (18)	27 (18)	4 (2.7)
The information I receive about vaccines from the government are reliable and trustworthy	13 (8.7)	123 (82)	11 (7.3)	2 (1.3)	1 (0.7)
Getting vaccines is a good way to protect my child from illness	68 (45.3)	76 (50.7)	6 (4)	0	0
In general, I do whatever my doctor or health-care provider recommends about vaccines for my child	32 (21.3)	112 (74.7)	6 (4)	0	0
I am concerned about serious adverse effects of vaccines	55 (36.7)	81 (54)	3 (2)	10 (6.7)	1 (0.7)
My child does not need vaccination for diseases that are not common anymore	68 (45.3)	60 (40)	1 (0.7)	18 (12)	3 (2)

Table 2

Factors influencing vaccine hesitancy

Factor influencing vaccine hesitancy	Adjusted OR	95% CI	P
Education of the mother (years)	0.607	0.406-0.907	0.015*
Education of the father (years)	1.438	1.007-2.055	0.046*
Husband’s use of social media (yes/no)	23.255	1.355-333.333	0.03*
Source of information related to vaccine#	4.356	1.222-15.526	0.023*

*P<0.05, #Doctor was used as the reference category – the other sources in the model were neighbors and friends, social media, radio, newspaper, and TV in that order. The OR represents the risk of vaccine hesitancy of each source of information with doctor as the reference. OR: Odds ratio, CI: Confidence interval

This study documented that the vaccine hesitancy among parents belonging to an educated, middle class, working population having easy access to social media in a metropolitan city of India. The main findings of the study are that there was a prevalence of 5.3% of high level of vaccine hesitancy. Television followed by the social media was the influential source for vaccine-related information. It was found that education of the mother protects against vaccine hesitancy, whereas father's education increases it. Father's use of social media and reliance on sources of information other than health-care providers increases the risk of vaccine hesitancy. The main drivers for vaccine hesitancy were skepticism against newer vaccines, concerns about safety and fear of adverse effects and the feeling that vaccines against uncommon diseases are not necessary. The following paragraphs will discuss these findings in detail. This study showed that vaccine hesitancy is not just a high-income country phenomenon but also it is present globally in all types of countries.[4] However, the exact burden of vaccine hesitancy in low- and middle-income countries is unknown. This study reveals preliminary findings of the prevalence of vaccine hesitancy of about 5.3%.

Vaccine-related health communication should be a two-way process, where listening to the perceptions and opinions of the community are as important as providing information. Providing knowledge and information is not enough; it should be associated with interventions based on behavior change communication theories such as the health belief model and transtheoretical model.[5] Many times, television, popular media, and social media use images of children with vaccine-preventable diseases, adverse events following immunization, misrepresentation of data related to vaccine safety, and efficacy to create fear in the communities about vaccines. This misinformation leads to vaccine hesitancy. Even messages which are intended to improve vaccine uptake such as information about the vaccine-preventable illness or messages against false claims about vaccines tend to be counterproductive. The current study also found that when the father had access to and used social media, it increased the risk of vaccine hesitancy. The finding of father's education is negatively related to vaccine hesitancy can be related to this. With greater education, there is probably greater use of social media among fathers. Furthermore, vaccine hesitancy was higher when the source of vaccine information was other than the health-care provider. Previous studies have shown that when the health-care provider is the source of information, vaccine hesitancy is lower.[6] Previous studies of vaccine acceptance in the same area for the newly introduced measles–rubella vaccine also revealed that trust in the health system and suspicions about new vaccines spread through social media campaigns had a strong influence in vaccine hesitation.[7] Parents use of social media carried greater amount of hesitancy risk. The findings of this study are likely to be different from the general population as the respondents were sampled from a tertiary care hospital. Further studies among communities are required. Therefore, vaccination programs and policies have to feature strong community engagement strategies to increase awareness about the vaccines, positive spread of news through media, and remove fears associated with vaccine uptake. Even among populations with near-universal vaccine coverage, vaccine hesitancy exists. Vaccine hesitancy should be evaluated thoroughly in the Indian context to strengthen the Universal Immunization Program. Media have played and continue to play a large role in disseminating information related to vaccines. While some strategies to mitigate the trend of increased vaccine hesitancy are already in place, additional interventions are needed to minimize concerns of the vaccine-hesitant parents. Reliable information through health-care providers should be provided through camps and awareness programs.

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Conflicts of interest

There are no conflicts of interest.