The Impact of Online Media on Parents' Attitudes toward Vaccination of Children - Social Marketing and Public Health

"...decision makers should pay more attention to modern forms of online communication and social marketing in order to use their potential for improvement of public health, as well as avoid the harmful impact that certain forms of communication may have on the formation of attitudes and loss of confidence in vaccines."

Studies have shown that more and more parents are searching for vaccination information online. Online sources represent a well-established and important site of health-related information and, moreover, they have a significant role in shaping health behaviours. However, online sources also contain misinformation that may negatively affect attitudes and behaviour and, as such, may have negative ramifications for public health. In developing countries, such as the countries of the Western Balkans region, a lower level of development of the health system and public health policy may result in online media having an even greater influence on the formation of attitudes and level of trust in vaccines. The aim of this paper was to investigate the level of influence of online media on parents' attitudes toward vaccination of children in three countries of the Western Balkans (Montenegro, Serbia, and Bosnia and Herzegovina) in order to understand how to maximise the potential of this form of communication - specifically, by directing social marketing activities to strengthen trust in vaccines, thus improving public health.

The paper is organised into five sections. The first section features a review of the results of previous research regarding vaccination and online media and explains how it motivated the present research. This section includes an analysis of key aspects of vaccination, arguments for and against vaccines, trust in vaccines, the role of online media, and the importance of social media in strengthening trust in vaccines, as well as the influence of a country's development on these issues. This portion of the paper also includes a description of research methodology. The next part presents the results of research, while the fourth part discusses these results. The paper concludes with closing remarks, a review of the implications, and recommendations for future research studies.

In brief, quantitative research was conducted online in the first quarter of 2020 using a survey method. A 20-item questionnaire was prepared and distributed to 3,031 parents online in the three countries in cooperation with preschool institutions (kindergartens) and parents' associations. The poll lasted for 30 days, and 1,593 fully completed polls were returned. The hypotheses were tested using standard statistical tests, including the ANOVA test, eta coefficient, and logistic regression.

Analysis revealed that about one-fifth of respondents do not trust or have a low level of trust in vaccines, and characteristics of respondents are correlated with the attitudes of parents towards vaccines, as shown in Table 3 of the paper. The results also indicated that online media have a significant influence on the formation of parents' attitudes toward the vaccination of children, which confirms the importance of the use of social marketing in order to direct communication properly and to strengthen the level of trust in vaccines. In addition, the results of logistic regression showed that the following groups of parents are particularly vulnerable to the influence of online media on attitudes toward vaccines: women, parents of younger age ("millennials"), parents who are in a common law marriage, and parents who have more children. Furthermore, the results showed that there is no statistically significant difference in the attitudes of parents in the three observed countries.

The results of the descriptive statistics showed that:

• 37.7% of cases used online health websites, then blogs and forums (33.6%), when collecting online data about vaccines; these two sources were the most trusted online media outlets.
• For 11.7% of respondents, Facebook is the primary online source for information about vaccines, while 4.2% prefer other social networks (Twitter, Instagram).
• When asked how they rate their understanding of the material they received through online media, 55.6% of respondents consider their understanding to be average, and 16.8% believe they have a complete understanding, while the remaining respondents are not satisfied with their understanding of the information they obtained online.
• The participation of parents who were more informed about pro-vaccine arguments (49.3%) and arguments against vaccination of children (50.7%) is almost equal, which makes sense, because those who seek additional information should want to know both positive and negative arguments on this topic.
• The "pressure" of pro-vaccine campaigns was felt by 13.74% of parents, while 40.55% felt the "pressure" of anti-vaccine campaigns.
• In collecting information on vaccination through online media, 53.2% of parents stated their spouse was also involved, while 46.8% of respondents stated they collected the information for themselves.
• Only 11.48% of respondents share vaccine information with others online, while 88.52% do not, although they use online sources to inform themselves. These results may be explained by the fact that parents in the analysed area still use "offline" sources of information (e.g., paediatricians: 27.4%) to form attitudes about vaccines. Since this is the way they get information, they still do not have the habit of sharing their views on vaccines with other parents in public, i.e., online.

Based on the results of the research, the authors offer some recommendations, including: Professional support must be present in all forms of application of online media and social marketing to the field of immunisation. The provision of information by health professionals and the quality of their information are essential for the decision to vaccinate or otherwise, which is important for communication through social media. Decision-makers should be aware that positive attitudes are key to a high level of confidence and that it is necessary to integrate a number of factors in order to maximise the application of social marketing in the field of medicine and public health.

"Finally,...it is evident that the effects of the pandemic of the new coronavirus Covid-19 will be manifested through direct influences on people's perception and attitudes about vaccination, especially when it comes to vaccination of children. In order to avoid the negative effects that online media may produce, decision-makers need to develop adequate online communication and social marketing strategies, for which the findings offered in this study may be very helpful and useful."