Vaccine Rejection and Hesitation in Turkey

"Public precautions and emergency measures similar to those in developed countries should also be taken against vaccine refusal in developing countries such as Turkey."

The fact that countries with lower levels of socioeconomic development have conducted fewer studies on vaccine refusal and hesitancy does not mean that vaccine refusal and hesitancy are at a low level in these countries. From 2016 to 2018, there was a 2% decrease in the vaccine rate in Turkey, and vaccine researchers and non-governmental organisations have started to investigate the causes of this decline. The Turkish Medical Association announced that the number of families who signed a vaccine rejection form in 2017 reached 23,000, a figure that was 183 in 2011 and 12,000 in 2016. The aim of the present study was to determine the prevalence of vaccination refusal in Turkey, in addition to the demographic features and underlying reasons, so as to inform possible solutions.

This descriptive cross-sectional study was conducted in İstanbul and Tekirdağ, two Turkish cities exposed to widespread internal migration. ("Particularly in the cities that are open to foreign migration due to the great opportunity for employment after the Syrian war, the present study may show the risks of preventable infectious diseases that may arise in the future.") To reflect Turkey's demographic structure, 1,004 participants were selected using cluster sampling based on birthplace, age, and level of education. A face-to-face questionnaire method was used. Sample findings:

• 2.39% (n = 24) of the participants did not know what a vaccine was. Lack of vaccine knowledge was more prevalent among low-education and low-income groups (p = .020; 0.022, respectively).
• 6.17% (n = 62) had not been vaccinated at any time during their lives.
• 89.34% (n = 897) answered "yes", 6.57% (n = 66) answered "no", 2.79% (n = 28) answered "I don't know", and 1.29% (n = 13) answered "hesitant" to the question, "Do you think vaccines are beneficial?" (The distribution of the reasons stated by individuals who were hesitant and who think that vaccines are non-beneficial is given in Table 6 of the paper.) A larger proportion of highly educated participants than those less educated stated that vaccines are non-beneficial (p < .001). More white-collar and low-income participants than any others stated that vaccines are non-beneficial (p < .001; p < .001, respectively).
• The number of participants who stated they do not trust healthcare workers was only 7 (0.70%).
• The number of participants who specified they do not trust vaccine companies was significantly higher in the young age, high-education, and high-income groups (p = .015; p = .002; p < .001, respectively).
• The number of participants who said, "I heard that vaccination is harmful on the television or the internet" was significantly higher in the young age group (p < .001).
• The number of female participants who said, "my family does not recommend vaccines; they say it is harmful" was significantly higher than that of men. These women mostly had a low-income or were housewives (p = .012; p = .013; p = .032).

The researchers draw some patterns from the findings, noting that 3 out of 10 women with a high educational level did not think that vaccination was beneficial, with the rate being 10 times higher than that in the low-education group. In particular, the individuals who rejected vaccines or who had vaccination hesitancy were mostly young mothers with high socioeconomic and income levels. Thus, the researchers suggest that the cause of the decrease decrease in Turkey's vaccination rate is not socioeconomic or income-related problems that lead to difficulties in accessing vaccines, as was the case before 2010; instead, the most important reason is vaccine refusal and hesitation.

The most common reason for hesitancy in this study was lack of trust in vaccine companies. Fifty percent of people who think vaccination is non-beneficial said they do not trust the vaccine companies, with approximately 5% of all participants indicating similar distrust. The second most common reason for vaccination hesitancy was hearing from the media and internet that vaccination is harmful, with 25% of all individuals saying they saw such information on social media. The majority of these individuals were young. In the researchers' opinion, although social media and the internet are important tools for public health, sometimes confusion and misinformation can occur, especially with modern parents with high educational and income levels.

In light of these findings, the researchers suggest that the World Health Organization (WHO) and the scientific circles working to increase the prevalence of vaccines should develop educational programmes directed at this young portion of society via social media. They also encourage local administrators, especially public health managers, to organise training programmes together with vaccination professionals in high schools and equivalent schools.

Approximately 1 in 10 participants stated their neighbours and family members say that vaccination is harmful. In Turkish society, where the familial bond and traditional lifestyle is still strong, this can be used positively to increase knowledge of vaccine usefulness; just as vaccine refusal became widespread due to this interaction, the same effect can spread the perception that vaccines are necessary.

In the present study, only 7 participants stated they did not trust healthcare workers, a rate that was much lower than that reported in the literature. The researchers believe that the reason for this low rate is related to easy access to primary preventive healthcare services in Turkey and efforts of healthcare workers. Thus, they indicate that "the most important force for reducing vaccine rejection and hesitation will be healthcare workers in family health centers, who will promote vaccine usefulness via educational videos showing the destruction that can be caused by vaccine-preventable diseases."