Evaluation of COVID-19 Vaccine Refusal in Parents

Abstract

Objective: 

The frequency of vaccine refusal, which is associated with many factors, is increasing worldwide. The aim of this study was to predict the frequency of vaccine refusal against domestic and foreign COVID-19 vaccines and identify the factors underlying refusal.

Methods: 

A survey consisting of 16 questions about COVID-19 vaccination was conducted either face-to-face or online with 428 parents who agreed to participate in the study. The parents had children who were inpatients or outpatients in the Children’s Hospital of Ankara City Hospital. In the survey, parents were asked about family sociodemographic characteristics, opinions on domestic and foreign COVID-19 vaccines, and reasons for vaccine refusal.

Results: 

While 66.1% of parents were reluctant to receive foreign COVID-19 vaccines, only 37.4% were reluctant to receive domestic COVID-19 vaccines. The participants’ preference for the domestic vaccine was significantly higher for themselves and their children (P < 0.05). Women were less likely to be willing to receive foreign vaccines than men (P < 0.05). As the education level increased, fewer parents preferred the domestic vaccine for themselves (P = 0.046) and their children (P = 0.005). Both domestic and foreign vaccine acceptability for parents and their children was higher among parents with high anxiety levels regarding COVID-19 infection (P < 0.05). The most common reasons for refusal were anxiety about vaccine side effects, lack of knowledge about the effectiveness of vaccines, and distrust of vaccines originating from abroad.

Conclusion: 

Most of the participants were hesitant about COVID-19 vaccines. This study demonstrates that vaccine uptake can be increased by considering the higher preference for domestic vaccines.

Severe acute respiratory syndrome coronavirus (SARS-CoV-2), the virus that causes COVID-19, is a novel infectious disease that was first seen and described in Wuhan, People’s Republic of China, in December 2019, and then spread rapidly throughout the world.¹ In March 2020, COVID-19 was declared a pandemic by the World Health Organization. The disease affects large numbers of people of all age groups worldwide. As of December 2020, around 1.5 million patients had died from COVID-19.² Preventive vaccines for COVID-19 or effective drugs to treat the disease have not yet been found. While treatment methods are being sought in many centers, effective vaccine development studies are in different phases of investigation both domestically and abroad. Some of these studies’ published preliminary results offer hope for effective vaccines in the near future.³

Vaccine hesitancy and refusal exist in many countries, including Turkey, and around the world, and the incidence of vaccine rejection is gradually increasing. As a result of decreasing vaccination rates, there has been a significant increase in the incidence of some vaccine-preventable diseases, such as measles, chickenpox, and hepatitis A, in recent years.⁴

Since no effective antiviral treatments have been developed to date, vaccination development studies are essential for individual health to prevent morbidity and mortality related to COVID-19 and for public health to control the pandemic in the future. Nevertheless, vaccine hesitancy and refusal are anticipated toward COVID-19 vaccines, which are expected to be available in the near future, including the vaccines in the national immunization program. Awareness of the rejection status against COVID-19 vaccines is necessary for public health and the fight against the pandemic. For this reason, the aim of this study was to reveal parents’ opinions about domestic and foreign COVID-19 vaccines, to determine the frequency of rejection of COVID-19 vaccines, and to understand the reasons for vaccine rejection and the factors affecting it.

MATERIALS AND METHODS

A survey about COVID-19 vaccination was conducted with 428 parents who agreed to participate in the study. The parents had children who were outpatients or inpatients in the Children’s Hospital of Ankara City Hospital. The survey was conducted face-to-face or online, for which the survey link was delivered to parents through social networks. Parents had to be volunteers with at least 1 child, and they did not receive any incentives for completing the survey. All of the parents provided informed consent before participating in the study.

The questionnaire consisted of 16 questions about the sociodemographic characteristics of the participants, their own and their family members’ chronic disease history and history of COVID-19 infection, history of death in the family due to COVID-19, preference to have a domestic or foreign COVID-19 vaccine whose effectiveness was demonstrated and that was approved by the authorities, whether they had previous vaccine rejection, and if they preferred not to be vaccinated and their reasons for refusal. In addition, participants were asked to provide a score between 0 and 10 for their level of fear and anxiety about COVID-19. A score from 0 to 3 points was evaluated as low, 4 to 6 points as medium, and 7 to 10 points as high.

The Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, NY) was used to analyze the data. Descriptive statistics (including frequencies and means) for all variables were calculated. The results were expressed as mean ± standard deviation, median and range (smallest value–largest value), and number (%) depending on whether the data were parametric or not. Quantitative data were compared using the χ² test. The level of statistical significance was established as P < 0.05.

This study was conducted in conformity with the principles of the Declaration of Helsinki and approved by the Ethics Committee of Ankara City Hospital Ethics Committee.

RESULTS

Of the 428 volunteers participating in the study, 272 (63.6%) were women and 156 (36.4%) were men. The mean age was 39.7 ± 10.7 years old, and the median age was 38 years old. Considering the education level of the participants, 2 (0.47%) were not literate, 2 (0.47%) were literate, 55 (12.9%) were primary school graduates, 104 (24.3%) were high-school graduates, 230 (53.7%) were university graduates, 27 (6.3%) had a master’s degree, and 8 (1.9%) had a PhD or beyond. The number of people living in the same house varied between 2 and 8 (mean 3.8 ± 1.7). While 12.6% of the participants had experienced COVID-19, 87.4% had not. There were 14.1% of participants who had a chronic disease, and 27.6% had at least 1 family member with one or more chronic disease living together in the same house. Among the participants, 27.3% had a family member who had been diagnosed with COVID-19, and 9.1% had lost at least one relative due to COVID-19. The fear and anxiety level about COVID-19 was 6.2 ± 2.7 on the scale from 0 to 10 points. Fifty-one of the participants (11.9%) had a previous history of vaccine refusal history to at least one vaccine in the national immunization program (Table 1).

TABLE 1. - The participants’ demographic and health-related characteristics and fear level (n:428)

Variables	n (%)
Age (yr) (mean ± SD) (median)	39.7 ± 10.7 (median: 38)
Gender
Male	156 (36.5%)
Female	272 (63.5%)
Education
Less than high-school degree	59 (13.8%)
High-school degree	104 (24.3%)
College degree and more	265 (61.9%)
Number of people living in the same house (mean ± SD) (min-max)	3.8 ± 1.8 (1–8)
Personal history of COVID-19 diagnosis
Yes	54 (12.6%)
No	374 (87.4%)
Family member ever diagnosed with COVID-19
Yes	116 (27.1%)
No	312 (72.9%)
Chronic disease
Yes	60 (14.1%)
No	368 (85.9%)
Family member with one or more chronic disease
Yes	118 (27.6%)
No	310 (72.1%)
Family member loss due to COVID-19
Yes	39 (9.1%)
No	389 (90.9%)
Any vaccine refusal history
Yes	51 (11.9%)
No	377 (88.1%)
Fear and anxiety level due to COVID-19 (mean±SD)	6.2 ± 2.7

When parents were asked if they would consider getting vaccinated with a foreign vaccine if it was reported to be effective against COVID-19, 33.9% answered that they would get vaccinated, while 66.1% stated they would not. To the question, “If a national vaccine is reported to be effective against COVID-19, would you consider getting it?” 62.6% of the participants answered that they would, while 37.4% stated they would not. When the data were evaluated statistically, it was seen that the preference for the domestic vaccine was significantly higher (P < 0.001) (Table 2).

TABLE 2. - Vaccine choice and acceptance of participants (n:428)

Preference	Willing (number, %)	P
For themselves
National vaccine	268 (62.6%)	<0.001
International vaccine	145 (33.9%)
For children
National vaccine	243 (56.8%)	<0.001
International vaccine	124 (28.9%)

When parents were asked if they would have their children vaccinated with a vaccine from abroad if it was reported to be effective against COVID-19, 28.9% answered that they would, while 71.1% stated they would not. To the question, “If a national vaccine is reported to be effective against COVID-19, would you consider getting it to your children?” 56.8% answered yes, while 43.2% said no. When the data were evaluated statistically, it was seen that parents preferred the domestic vaccine over the foreign vaccine for their children (P < 0.001) (Table 2).

Looking at gender and vaccine preference, women were less likely to be willing to get a domestic (P < 0.05) or foreign (P = 0.001) COVID-19 vaccine than men. When asked about their willingness to have a domestic or foreign COVID-19 vaccine administered to their children, 25.1% of women and 35.9% of men stated they would have the foreign vaccine administered to their children, and 54.6% of women and 60.8% of men stated they would have the domestic vaccine administered to their children. In comparison, the preference for the foreign vaccine for children was higher in males than females (P < 0.05), but no significant difference was found between the sexes for domestic vaccines (P > 0.05).

As the education level increased, parents were less likely to accept the domestic vaccine for themselves (P = 0.046) and their children (P = 0.005). Conversely, no significant correlation was found between education level and preference for the foreign vaccine for themselves and their children (P > 0.05).

There was no correlation between willingness to be vaccinated with the domestic or foreign vaccine and having had COVID-19, having a family member ever diagnosed with COVID-19, having a chronic disease, having family members with a chronic disease living together in the same house, or having lost any relatives due to COVID-19.

Both domestic and foreign vaccine acceptability for themselves and their children was higher among parents whose fear and anxiety levels were high (P < 0.05).

While 80.4% of the parents who had a history of vaccine refusal were reluctant to receive the foreign vaccine, 86.3% were reluctant toward the foreign vaccine for their children. Additionally, it was observed that 62.7% were reluctant to receive the domestic vaccine for themselves, and 70.5% were reluctant for their children. It was found that the preference for the domestic vaccine was much higher than the foreign vaccine in this group (P < 0.05) (Table 3).

TABLE 3. - Vaccine choice and acceptance of the participants who had a history of vaccine refusal (n:51)

Preference	Willing (number, %)	P
For themselves
National vaccine	19 (37.3%)	< 0.05
International vaccine	10 (19.6%)
For children
National vaccine	15 (29.4%)	< 0.05
International vaccine	7 (13.7%)

The participants who were not willing to have a domestic or foreign COVID-19 vaccine identified the following factors as their reason for refusal: avoiding possible vaccine side effects (40.4%), not knowing the precise effectiveness of the vaccine (38.3%), distrust in vaccines from abroad (29.4%), concerns about excipients in the vaccine (22.7%), not believing in the effectiveness of vaccines (9.3%), not having fear or anxiety about COVID-19 infection (6.8%), distrust in domestic vaccines (5.3%), thinking he will not have COVID-19 again (3%), religious reasons (2.1%), believing the virus will mutate so that the vaccine will be ineffective (1.2%), distrust in companies developing vaccines (0.7%), and thinking that the vaccines might contain microchips (0.2%).

DISCUSSION

Vaccine hesitancy and refusal mean delaying or refusing to accept vaccination despite the availability of vaccination services.⁵ As seen around the world, cases of vaccine rejection are increasing in Turkey, and the impact of the COVID-19 pandemic on vaccine hesitancy and refusal is not yet known. In this study, determining the rates of parental hesitancy and refusal of COVID-19 vaccines is essential for future vaccination programs to understand the reasons for vaccine rejection and the factors affecting it.

This study found that 62.6% of parents were willing to have a domestic vaccine, while only 33.9% were willing to have a foreign vaccine. A study by Reiter et al found that nearly 70% of adults in the United States would be willing to accept a COVID-19 vaccine.⁶ Yilmazbaş et al determined that approximately 74% of the participants in their study would get a COVID-19 vaccine.⁷ In the present study, the preference of participants with a history of vaccine rejection for the domestic vaccine was significantly higher. Since there are vaccine development studies underway in different centers in Turkey, it is essential for the national immunization program to recognize the preference for the domestic vaccine, which was demonstrated in this study for the first time.

When the attitude toward vaccination was examined according to gender, the acceptance rate for domestic and foreign vaccines was found to be higher in men. Detoc et al also found that men were more accepting of vaccines than women.⁸

Vaccine refusal cases have been seen in Turkey for the last ten years and are increasing gradually. While only 180 families refused vaccination in 2011, this number approached 25,000 as of 2018.⁴ In this study, the rate of those with a previous history of vaccine rejection was found to be 11.9%. Similarly, Detoc et al found the history of vaccine rejection to be 12.1%.⁸

There are many factors, such as social, cultural, political, and economic, that affect vaccine hesitancy and refusal. Opel et al’s research has demonstrated that parents with higher education levels are approximately four times more likely to worry about vaccine safety than those with lower education levels.⁹ Conversely, in a study by Bertoncello et al, a low education level was associated with vaccine refusal.¹⁰ There was no significant relationship between education level and foreign vaccine preference in this study, but when the relationship between education and domestic vaccine acceptance was examined, it was found that vaccine rejection increased significantly as the education level increased.

The frequency of vaccine-preventable diseases, such as measles, chickenpox, and hepatitis A, has decreased significantly, especially since the 1960s, thanks to effective vaccination programs. Unfortunately, with this decline, the fear of these diseases has been replaced by fear of vaccination.¹¹ The rapid spread of COVID-19, its morbidity and mortality, and the inability to develop an effective treatment have caused people to approach this disease with fear. Detoc et al found that as the level of fear from the disease increased, the frequency of vaccine rejection decreased.⁸ Similarly, in this study, it was found that as the level of fear from the disease increased, the frequency of vaccine acceptance increased.

Previous studies have indicated that the reasons for vaccine hesitancy and refusal include thoughts that the chemical substances in vaccines are harmful to human health, distrust of the companies producing vaccines, and that it is possible to protect against these diseases naturally by consuming certain foods.^4,12,13 The most common reasons for refusal given by the participants in this study were anxiety about vaccine side effects, not knowing the effectiveness of the vaccine, distrust in vaccines from abroad, concerns about excipients in the vaccine, and not believing in the effectiveness of vaccines.

CONCLUSION

The development of effective vaccines will be an important milestone for public health and combating the COVID-19 pandemic. In this respect, it is essential to know the frequency and reasons for vaccine hesitancy and refusal and to develop a national vaccination strategy accordingly. The data obtained from this study are similar to other studies and are supported by them. In addition, sociocultural values and orientations of societies are factors that should be carefully considered when planning vaccination programs. The present study identified a critical factor affecting our society’s vaccination behavior, which is preference for a domestic vaccine. Awareness of this factor may reduce COVID-19 vaccine refusal and guide future planning and development of public health studies.