Introduction

Vaccines are biological products used to stimulate the immune system for preventing infectious diseases. People are vaccinated for two reasons; to protect from the disease and to stop community spread. Vaccination is, therefore, one of the basic preventive health measures (1,2). Vaccinating a critical number of individuals in a community reduces the risk of outbreaks of infectious diseases and therefore protects other members of the community. Thanks to those who can be vaccinated, the protection of non-vaccinated sections of society is of philosophical value. The concept of “herd immunity” refers not only to epidemiological and technical aspects but also to some sort of social solidarity. Herd immunity is the highest indicator of social solidarity against the self-centred, individualistic, selfish, and neoliberal approach to health and well-being (2).

Although childhood immunization schedules are essential, the anti-vaccination movement is a serious threat to public health. The anti-vaccination movement is parallel to the history of vaccination. Compulsory vaccination policies introduced for community health care had exerted great efforts to counter the anti-vaccination movement. However, these days, parents are influenced by the growing reach of the anti-vaccination movement on social media and news media platforms, and therefore, doubt the effectiveness and safety of compulsory vaccination. Dr. Andrew Jeremy Wakefield, a gastroenterologist, published a study (1998) in the Lancet, postulating a connection between the measles-mumps-rubella vaccine and autism, which sparked controversy all over the world. Although his study had only 12 participants and a problematic methodology, it attracted global attention in the media, resulting in a growing number of parents refusing to get their children vaccinated. After 12 years, Wakefield was found to use some fabricated data and act unethically. Therefore, his paper was retracted by the Lancet, and his medical license was revoked in 2010 (3).

Fifteen years ago, there were no known and recorded cases of anti-vaccination in Turkey. However, the anti-vaccination movement has gained momentum since 2010. While at first there was no more than a handful of parents refusing to get their children vaccinated, the number went up to 970 in 2015, and 23,000 in 2017, which is a growing health concern (4). Turkey is a migrant-receiving and refugee-hosting country. If the number of anti-vaccination people continues to increase at this rate, immunization rates will drop further, and preventable diseases will cause an outbreak, and there will be a rise in the incidence of diseases that we thought have disappeared, which is unfortunately confirmed by the World Health Organization. While the number of cases of measles reported in Turkey was more than eight thousand in 2013, it was only 9 (nine) in 2016, which, however, increased up to 69 in 2017, 716 in 2018, and 2890 in 2019 (5).

Vaccination is still the most effective and cheapest measure to prevent infectious diseases. Therefore, adhering to the national vaccination schedule is very critical for both personal and community health, especially in Turkey, which is a country of migration (6).

Our aim in this study was to determine numerical data on the views and experiences of parents and healthcare professionals (physicians, nurses, midwives, etc.) and to discuss the ethical dimension of vaccination in light of these data.

Methods

This was a descriptive, cross-sectional study. The study population consisted of all parents referred to the polyclinic and clinic of paediatrics at a university hospital in Ankara between 11 February and 22 March 2019, and all physicians, nurses, and midwives in the department of paediatrics and childhood vaccination. No sampling was performed. Participation in the study was voluntary. Participants were informed about the study and their consent was received. Ethics committee approval was obtained for the study. The study was approved by the Medical and Health Sciences Research Board (project no: KA 19/52) and funded by the Research Fund of Baskent University Ankara.

Data were collected using two questionnaires developed. The questionnaires were created by the authors. All of the questions in the questionnaire are presented in the tables, based on the researchers’ experience and literature review (3,6-9). The questionnaire for parents consisted of 12 items on sociodemographic characteristics and anti-vaccination. Item 12 investigates whether parents agree with the portrayal of vaccination in the media. The questionnaire for healthcare professionals consisted of ten items on sociodemographic characteristics and anti-vaccination.

Statistical Analysis

Number (n) and percentage (%) were used for categorical data on anti-vaccination. Data were analysed using the Statistical Package for Social Sciences (IBM, version 25.0) at a significance level of 0.05.

Results

Evaluation of Parents

Eighty parents agreed to participate in the study. Of parents, 56.3% were women, 89.9% were married, 68.8% had a bachelor’s degree, 57.5% had a single child, 28.7% had two children, and 13.8% had three children. Parents were engineers and architects (24.1%), teachers (13.9%), housewives (12.7%), self-employed (11.3%), civil servants (7.6%), lawyers (6.3%), physicians (6.3%), pharmacists (5.2%), nurses (1.3%), and others (11.3%). Seven participants (8.8%) self-identified as “anti-vaccination”.

Five anti-vaccination parents (71.4%) stated that they made the decision as a couple not to get their children vaccinated. Consuming organic foods (41.7%) was stated to be the most common alternative to vaccination. Anti-vaccination parents (54.5%) mostly believed that vaccinated children were more likely to contract diseases than vaccinated ones. Five of the anti-vaccination parents (83.3%) stated that they had no reaction from others about their anti-vaccination (Table 1).

Thirty parents (37.5%) stated that they knew enough about vaccines. Forty-nine parents (37.7%) stated that they were informed by healthcare professionals. Fifty-four parents (67.4%) stated that they would like to know more about vaccines (Table 2).

Parents specified that they believed that vaccination was the most effective method for preventing infectious diseases (91.2%), that their decision not to vaccinate their own children could put other children at risk for infectious diseases (87.5%), and that refusing childhood vaccination was a threat to public health (85.0%) (Table 3).

Evaluation of Healthcare Professionals

Thirty-six healthcare professionals agreed to participate in the study. The mean age of healthcare professionals was 44 years. Of healthcare professionals, 72.2% were women, 47.2% were nurses, 25% were specialist physicians, 16.7% were assistant physicians, and 11.1% were midwives, 22.9% had 21-25 years of experience, 20% had 1-5 years of experience, 5.7% had 6-10 years of experience, 11.4% had 11-15 years of experience, 20% had 16-20 years of experience, and 20% had ≥25 years of experience.

According to the findings from healthcare professionals, in the institution where the study was conducted, information about vaccination was provided to families by physicians at a frequency of 88.9%. Only two healthcare professionals (5.6%) stated that they encountered anti-vaccination once or twice a month. According to healthcare professionals, the main reason for parental anti-vaccination was the belief that “vaccines contain mercury, aluminium, ether, antibiotics, and many other chemicals, which cause autism and similar diseases” (15.9%). Thirteen healthcare professionals (nurses and midwives) stated that they referred anti-vaccination parents to physicians while nine stated that they found out why and tried to correct their misconceptions (Table 4).

Discussion

In this study, seven parents (8.8%) refused to get their children vaccinated. Türkay et al. (7) reported that 6.2% of parents self-identified as “anti-vaxxers.” This finding is similar to our study.

Most parents (71.4%) stated that they and their spouses agreed not to get their children vaccinated, which has been reported by Çapanoğlu (3) as well. Erdem et al. (8) conducted a study on oral polio anti-vaccination and reported that it was mostly mothers (55.3%) who chose not to have their children vaccinated.

According to Türkay et al. (7), self-identified anti-vaxxers do not trust vaccine companies (2 people, 6.4%) and believe that vaccines are useless (6 people 19.4%), have side effects (20 people, 65%), contain harmful substances (8 people, 25.8%), and cause infertility (1 person, 3.2%). Our result is similar because the participating parents stated that they believed that vaccinated children were more likely to contract diseases than unvaccinated ones and that vaccines caused autism and cancer, hinting that the reason for their anti-vaccination is mostly related to the possible side effects of vaccines.

The participating anti-vaccination parents stated that they fed their children with organic foods, kept them away from crowds and dirty public spaces and other vaccinated children, and trusted in God. Studies in Australia show that anti-vaccination people use complementary and alternative medicine therapies more because they believe that they are natural, non-chemical, and reliable methods with no side effects (10). Hazır (9) reported that anti-vaccination parents believed in fate (8.7%), kept their children away from crowds and patients (8.7%), and fed them with organic and healthy food (25%) or did nothing (57.6%) to protect their children.

Thirty parents (37.5%) stated that they knew enough about vaccination while 54 parents (67.4%) stated that they would like to learn more about it. In another study, 78.3% of parents stated that they knew enough about vaccination; however, 48.7% stated that they would like to learn more about it (9). The sources of information on vaccines are healthcare professionals (37.7%), Internet/social media (30.8%), and friends/relatives (30.8%). İncili (11) also reported that the sources of information about vaccines were doctors (82.6%), television, radio, and newspaper (11.6%), the Internet (1.9%), and neighbors (3.9%). The fact that most parents receive information from healthcare professionals about vaccination is a positive outcome. More than half (55%) of adults in the United States learn about health online. In a study on seven Internet search engines, more than 43% of the top 10 sites were revealed to contain antivaccine information (12). According to Türkay et al. (7), parents get information about vaccinations from TV (49.3%), the Internet (44.2%), and physicians (41%).

The statements “giving a baby too many vaccines (numerous and different types of antigens) disrupts its immune system and causes diseases,” “I think that vaccines have some damaging and long-term side effects that are not yet known,” and “I think that vaccines have some damaging and long-term side effects that are not yet known” are a sign of parents' anti-vaccination and fear about vaccinations. Despite these statements, the rate of anti-vaccination (8.8%) was low among our participants, suggesting that parents are mostly aware of their responsibility for herd immunization and solidarity, despite anti-vaccination and fear.

In the institution where this study was conducted, parents are mostly informed about vaccines by physicians (88.9%) in detail (35.4%). However, fifteen healthcare professionals (31.2%) stated that they did not do any explaining about vaccines unless parents asked for it and on the assumption that parents already knew about them (6.3%), which is not very good, because anti-vaccination is often discussed in the media and the public arena. This is supported by Çapanoğlu (3), who reported that healthcare professionals indulged in some self-criticism and took responsibility for anti-vaccination as partly their failure to provide information to parents.

According to the participating healthcare professionals, the factors affecting parents’ vaccine acceptance are communication and media tools, sociodemographic characteristics, use of conventional methods instead of vaccination, ignorance, and concern about vaccine-related side effects. Çapanoğlu (3) has also reported that according to healthcare professionals’ experience and observation, parental anti-vaccination depends on sociodemographic characteristics (being a young inexperienced mother, etc.), concern about vaccines (the belief that vaccines cause infertility and autism), religion, and social media.

The participating physicians stated that they corrected the misconceptions held by anti-vaccination parents about vaccinations and tried to persuade them to have their children vaccinated, whereas nurses and midwives stated that they referred those parents to physicians. Five healthcare professionals (12.5%) stated that they respected parents’ decision not to vaccinate their children. Healthcare professionals (65.2%) stated that they would advise anti-vaccination parents while 14.8% stated that they would not (13).

The great majority of our participating healthcare professionals (91.7%) were against leaving childhood vaccination decisions to parents. Arıcan (13) also reported that 93.6% of healthcare professionals were for compulsory vaccination according to the national immunization schedule. This indicates that healthcare professionals are aware that vaccination is an important and effective way for infectious disease prevention.

The study has some limitations. First, it was conducted in only one university hospital, and state-run hospitals and other university hospitals were not included. Second, the results are sample-specific and not generalizable to the whole population.

Ethical Assessment and Conclusion

Based on certain unfounded doubts and beliefs (vaccines cause autism and cancer; breastfeeding is better than vaccination, etc.), the anti-vaccination movement argues that vaccine regulations infringe upon individual autonomy and liberty. It is, of course, an important ethical value that we should respect the right of people to make choices of their own free will. However, what is generally overlooked is that limiting one's actions that harm other individuals is not the same as curtailing one’s freedom (2). It should always be kept in mind that a person who causes harm, whether by acting or failing to act, is held responsible for that harm either for acting or for failing to act (14).

Given all of the above, the basic arguments of vaccination in terms of ethical values are

- Both individual autonomy and social utility should be protected,

- We should always keep in mind that vaccination is vital for the protection of children’s right to life (15).

Instead of telling anti-vaccination about what they already know, we should raise their awareness of the behaviors they already exhibit for public health and get across to them that childhood vaccination is a vital public intervention that plays a key role in controlling and eliminating infectious diseases and in protecting public health (16).

Acknowledgement

We would like to thank the medical faculty students, Azın Aram, Berkehan Erkılıç, Betül Ankın, Elif Yağmur Dal, Merve Özcelik, and Nazmiye Tansu Güler, for their assistance in collecting the questionnaires and transferring the data to the software.

Ethics

Ethics Committee Approval: The study was approved by the Medical and Health Sciences Research Board (project no: KA 19/52) and funded by the Research Fund of Baskent University Ankara.

Informed Consent: Participants were informed about the study and their consent was received.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: S.D.K., Design: S.D.K., H.Y.Z., Data Collection or Processing: S.D.K., H.Y.Z., Analysis or Interpretation: S.D.K., H.Y.Z., Literature Search: S.D.K., Writing: S.D.K., H.Y.Z.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.