Vaccine-hesitant parents' reasons for choosing alternative protection methods in Turkey

Abstract

Background

Parents use alternative protective methods instead of having their children vaccinated because of their various concerns.

Aims

The aim of this study is to examine the processes by which the parents preferred alternative methods rather than the vaccines to strengthen their child's immune system.

Methods

Semi-structured, qualitative interviews were conducted with 22 parents who had vaccine hesitancy. The study sample consisted of parents whose children were between the ages of 0 and 18 years and who experienced vaccine hesitancy and lived in Turkey. The interviews with individuals were conducted online and aimed to be representative of the population of Turkey.

Results

The factors that caused parental vaccine hesitancy were various, such as vaccine contents, distrust of healthcare workers and false information about vaccines. Because of these factors, parents resorted to natural nutrition, vitamin support and some other precautions, such as avoiding takeaway food or preparing homemade food, rather than having their children vaccinated.

Conclusions

In recent years, it is thought that parents need education about vaccination; outbreaks may be caused by immigrant children who cannot be registered, and therefore cannot be vaccinated, in Turkey, which has received immigration at a high rate.

Keywords

childhood vaccination immigrations' vaccine parental parental belief Turkey vaccine hesitancy

Introduction

Vaccination is the immunisation carried out by means of injecting weakened bacteria or viruses or antigenic fragments into the body. Although vaccines are not one hundred percent effective, they are widely used in the community (WHO, 2014a). Vaccination is the most effective way to prevent the morbidity and mortality caused by infectious diseases (CDC, 2014). In addition to benefits, in history, there has always been a group advocating that vaccines can be harmful (WHO, 2014a, 2014b). Individuals who have vaccine hesitancy are at the centre of these attitudes. The World Health Organization (WHO) defines ‘vaccine hesitancy’ as a delay in acceptance or a refusal of vaccines despite the availability of vaccination services (WHO, 2014b). People who experience vaccine hesitancy may refuse some vaccines but accept others. Although they may delay or accept the vaccination, they may not feel assured in terms of being vaccinated (WHO, 2014a). A study carried out in the US reported that 77% of parents were concerned about one or more vaccines (Kennedy et al., 2011). Vaccine hesitation has gained more importance worldwide in recent events. In particular, the COVID-19 outbreak, which has spread all over the world from Wuhan, China and has been declared as a pandemic by the WHO, reveals this importance. Children whose parents had hesitation in vaccination are thought to be in greater danger (CDC, 2020; WHO 2020).

In recent years, Turkey has for various reasons been exposed to an extensive migration wave. The United Nations Refugee Agency (UNHCR) announced that in 2018 Turkey hosted 3.6 million Syrian refugees (UNHCR, 2018). Of these refugees, 23% were children whose vaccination status was unknown (Korkmaz, 2014).

The WHO reported that various infectious diseases were encountered in the refugee camps located in Jordan, Lebanon, Iraq and Turkey (WHO, 2014a). Especially in Turkey, the number of measles cases today is 20 times higher than the rate experienced in 2012. Furthermore, many infectious skin and other diseases such as cutaneous leishmaniasis, tuberculosis, diphtheria and whooping cough have begun to emerge again (Gültaç and Balçık, 2018; Wood, 2018).

Despite trying to create healthy living conditions for refugees, available resources are insufficient at times. The incidence of infectious diseases has significantly increased with the high number of unvaccinated children living in poor health conditions. This situation, combined with vaccine hesitancy, is becoming a public health hazard (Çapanoğlu, 2018; Gültaç & Balçık, 2018; UNHCR, 2018). Therefore, it is crucial to determine the reasons behind Turkish parents' vaccine hesitancy and their decisions against vaccinations despite current risks. Determining alternative preventive methods in place of vaccinations can also guide future initiatives. We believe personal opinions will prove very valuable during this process.

Most of the existing studies on childhood immunisation in Turkey were carried out using quantitative methods, and vaccine hesitancy has not been examined in depth. Despite being an especially important issue for paediatric nurses, no qualitative study has been found. We aimed to overcome this by learning the thoughts of parents about vaccine hesitancy using a qualitative approach. The purpose of this study was to examine the reasons parents shared for choosing alternative protection methods over vaccines to strengthen their child's immune system.

Method

Type of research

This study used a phenomenological, qualitative research design.

Study population

Our data set consisted of 22 individuals who posted anti-vaccination comments on Facebook pages. These people posted comments in response to anti-vaccine posts. We focused on the people who commented on three Facebook pages to understand the beliefs of anti-vaccine individuals. The researchers became members of anti-vaccine groups with their personal accounts. With the permission of the owners of these Facebook pages, we announced on their pages that were undertaking work on ‘vaccination hesitation’. The parents who responded to our social media post were informed that this was a scientific study. A consent form was shared with the parents, and correspondence continued with those who agreed to participate in the study. Four parents refused to participate in the study, thinking that we would try to change their mind. Three online interviews were not included in the analysis, as sufficient answers were not received from the families. The answers of the first five people we interviewed were evaluated. These responses were excluded from the study; however, in line with the responses of these five people, necessary changes were made in the semi-structured form. We used this form to conduct in-depth interviews with 22 people in the form of Facebook page correspondence.

Place and time of research

Semi-structured, qualitative interviews were conducted with 22 parents who experienced vaccine hesitancy. The interviews were conducted online on Facebook pages with individuals representative of the population of Turkey, who benefited the study by showing a diversity of sociodemographic characteristics. Those who agreed to participate in the study indicated when they were ready for online talks. The duration of the interview lasted an average of 50 minutes, with a minimum of 26 and a maximum of 68 minutes. The data collection and analysis processes of the research were completed between March and June 2019.

Sample selection and exclusion criteria

The sample comprised parents of children aged 0–18 years who had refused one or more childhood vaccination for various reasons, and who had voluntarily agreed to participate in the study. No incentives were given to the participants.

Data collection tools

Personal information form

To determine the sociodemographic characteristics of the participants, a Personal Information Form was prepared in line with the literature.

Semi-structured interview form

We developed a semi-structured interview guide based on previous answers. There is an alternative to each question on this form. When comprehensive information about the subject was reached, the questions to be included in the form were identified and listed (Appendix 1 – Supplementary material).

Data analysis

After the interviews, we performed content analysis using thematic analysis. All data were recorded in Microsoft Word files together with case numbers. We formed subheadings to code and categorise the collected data. All participants were interviewed online. Interviews were uninterrupted and lasted an average of 50 minutes. The interviews were conducted following the survey guide, not in a ‘question-and-answer’ format. To strengthen the quality of data analysis, all the researchers performed one-by-one analysis before the data were combined. The data collection process was carried out simultaneously with the analysis. The data collected from the participants were continuously compared. According to these comparisons, categories were created from the raw data. When analysing the data, the correspondence and analysis on the social media platforms were documented verbatim.

Findings

Sociodemographic data of the participants are shown in Table 1. Three main themes of the study emerged, and subthemes and related codes were created and analysed as follows. Main themes and subthemes are:

Vaccination Thoughts/Factors Affecting Non-Vaccination Decision

Not finding vaccines safe

Content of the vaccines

Side effects and negative experiences

Autism due to vaccination

Distrust of healthcare system and healthcare workers

Thoughts that vaccines are imported and a commercial trick

Religious beliefs

Information source of the vaccination

Internet and social media/foreign publications (books)/Google Scholar

Being influenced by anti-vaccine doctors

The Impact of Non-Vaccination on Community Health

The thought that the unvaccinated children do not affect the public

The thought that the child is affected negatively or positively by the migration wave

Not to be affected by migration

Methods Used to Keep the Child's Immune System Strong

Natural methods/additive-free nourishment

Table 1.

Sociodemographic information of parents.

Participants	Age	Gender	Nationality	Education	Occupation	Number of children	Child age
IN1	29	Woman	Republic of Turkey	Bachelor's Degree	History teacher	1	2.5 years
IN2	38	Woman	Republic of Turkey	High school	Stylist	1	4 years
IN3	36	Woman	Republic of Turkey	Bachelor's Degree	Housewife	1	3.5 years
IN4	32	Woman	Republic of Turkey	Bachelor's Degree	Banker	1	28 months
IN5	34	Woman	Republic of Turkey	Bachelor's Degree	Turkish Teacher	1	3.5 years
IN6	33	Woman	Republic of Turkey	Bachelor's Degree	Information Technologies	1	18 months
IN7	30	Woman	Republic of Turkey	Bachelor's Degree	Accountant	1	2 years
IN8	31	Woman	Republic of Turkey	High school	Housewife	1	5 years
IN9	29	Woman	Republic of Turkey	Bachelor's Degree	Gym teacher	1	3 years
IN10	29	Woman	Republic of Turkey	Bachelor's Degree	Housewife	1	4 years
IN11	34	Woman	Republic of Turkey	High school	Housewife	2	7 years/1 year
IN12	32	Woman	Republic of Turkey	Bachelor's Degree	Pre-school teacher	2	5 years/ 8 months
IN13	29	Woman	Republic of Turkey	Bachelor's Degree	Gym teacher	1	4.5 years
IN14	33	Woman	Ukraine	Bachelor's Degree	Pharmacist	2	5 years/ 6-month pregnant
IN15	39	Woman	Republic of Turkey	Bachelor's Degree	Teacher	2	12 years/18 years
IN16	29	Woman	Republic of Turkey	Secondary School	Housewife	3	10, 7 years and 1 year
IN17	34	Woman	Republic of Turkey	Master's Degree	Industrial Engineer	1	10 months
IN18	35	Woman	Republic of Turkey	High school	Housewife	4	8 years, 6 years, 4 years
IN19	28	Woman	Republic of Turkey	Bachelor's Degree	Housewife	1	1.5 years
IN20	30	Woman	Republic of Turkey	High school	Housewife	1	3.5 years
IN21	34	Woman	Republic of Turkey	High school	Housewife	1	5 years
IN22	36	Man	Republic of Turkey	Bachelor's Degree	Electrical and electronic engineer	1	5 years

Vaccination thoughts/factors affecting non-vaccination decision

The thoughts about the vaccine and the factors affecting the decision not to vaccinate were categorised under the three main themes. In this study, we demonstrated with the first main theme the factors that parents took into account when deciding not to vaccinate their children. It was determined that 13 (59%) of the participants in our study did not give their children any vaccine.

Not finding vaccines safe

Two subcategories were created regarding the idea that parents did not find the vaccines safe: contents of vaccines and side effects and negative experiences.

Contents of vaccines

One of the participants stated that she did not receive the vaccine after the second month because of the vaccine contents:

I'm not against the vaccines; actually, what I'm against is the substances in the vaccines. Infants do not have an active immunity until the twelfth month, so what are these vaccines being used for? (IN8)

In our study, some participants decided not to have their children vaccinated because they thought that vaccines contained mercury:

I think that vaccine has the most effect on autism. Are we aware of the fact that the vaccines have been developed a lot? They are more harmful than before. Mercury remains in the body. (IN9)

They add thimerosal (mercury), aluminum, aluminum hydroxide, formaldehyde, hydrolyzed gelatin, and bovine serum as preservatives … (IN5)

Some participants decided not to have their children vaccinated because of questionable substances in the vaccine. One of these participants said:

There are some articles saying that they even contain human sperm. There can be no rational explanation for injecting such a thing into the body of my child. (IN19)

Can you believe that there is even washed sheep's blood in the vaccine? Which health worker knows this fact? (IN20)

Side effects and negative experiences

Negative experiences after children were vaccinated were shown to affect parents' decision to refuse vaccinations. In our study, eight of the participants had negative post-vaccination experiences in their children.

My child had an allergic post-nasal drip and an otitis media after the vaccination at the age of one year. He could not hear for a year. His intestinal flora deteriorated due to the antibiotic drugs used. I think that vaccines are weapons of mass destruction. (IN3)

Autism due to vaccination

In the interviews, there were parents who thought that vaccines had a strong relation to autism.

After my niece was diagnosed with autism in 2013, the hard times started for us. After our visits to many doctors, dear Dr. A.A. found the diagnosis. After the mixed vaccine, my niece's relationship with her mother was broken. She stopped breastfeeding. She could say ‘mom’ and ‘dad’, but later she stopped saying something and became introverted. (IN2)

Distrust of healthcare system and healthcare workers

In our study, participants stated that they refused to have their children vaccinated because of their distrust in the healthcare system and healthcare workers:

… Especially the nurses are very insufficient in this issue. Family physicians are also worse than them. He (physician) said, ‘I cannot say that it is zero percent harmful’. Frankly speaking, he didn't seem to know anything while saying this. (IN17)

Thoughts that vaccines are imported and a commercial trick

In our study, six parents stated that they thought that vaccination was a commercial trick because the vaccines were imported, and they had trust issues.

So, don't you think that the vaccine companies are doing this? I mean that they caused a lot of diseases such as bird flu, swine flu and Crimean-Congo haemorrhagic fever to increase their sales. (IN 17)

Religious beliefs

There were parents who did not have their children vaccinated because they thought it was haram (forbidden by Islam). Statements from two of them were as follows:

… Not because it contains mercury and aluminum or my child will be autistic, but because it is haram. It's like mixing the halal (permitted by Islam) with the haram. (IN2)

When I questioned whether it was haram or halal, of course they said ‘halal’, but I made a search and found that it was nothing of the kind! (IN18)

Information source on vaccinations

The parents' main sources of information on vaccination were categorised under two subgroups.

Internet and social media/foreign publications (books)/Google Scholar

Most of the parents (eight) stated that they had received information about the vaccine from social media groups on the internet, such as those found on Instagram. One person claimed to have researched academic papers. The most striking statements were as follows:

I follow some pages on Facebook and Instagram. They share very useful information. These are the efforts of a handful of people who want to reveal the truth for us. And, these people provide their proof very well. (IN18)

Well …, even when making a search about the contents of vaccines in Google Scholar, a lot of things come out. After reading them, I decided … (IN17)

Being influenced by anti-vaccine doctors

Parents stated that some healthcare workers were more positive about vaccine refusal because they did not recommend the vaccination. There were also parents who were influenced by the publications of anti-vaccine doctors, and they decided to refuse the vaccinations. Seven participants gave the names of some doctors and lecturers and stated that they had read papers published by these people. The most striking statements were as follows:

I started to follow physicians such as A.Y., Y.D., and A.R.K. A.Y. is an immunologist and says that ‘the vaccines administered to a baby in the first two years to strengthen the immunity suppress the immune system. If you want your child to be vaccinated in any case, you should start the vaccination after the age of two years’. This makes sense to me … (IN1)

The impact of non-vaccination on community health

The thought that the unvaccinated children do not affect the public

Immunity to disease as a result of high vaccination rates in the public is called ‘herd immunity’. When an infectious disease reaches the percentage needed for herd immunity, unvaccinated persons are protected just as the vaccinated ones. Some participants thought that the unvaccinated children would not affect the public:

I do not think that those who are not vaccinated at the moment are enough to have a positive or negative impact on public health. Even if the number increases, I don't think it will affect it. (IN1)

The thought that the child is affected negatively or positively by the migration wave

In the interviews with parents, after we mentioned that unvaccinated children could affect public health, we asked for their thoughts about the migration wave. Interestingly, some parents stated that the children would not be adversely affected by migration and even thought that the immigrant children were healthier. Some stated that they did not find the vaccine protective, while others did not want the vaccination because they thought that the disease passed from the immigrant children.

Not to be affected by migration

In this study, there were five parents who stated that immigrants did not affect their thoughts about the vaccine.

… we live in a touristic place. Different kinds of tourists come every year. Up to now, I've never heard of an infectious disease. I just don't believe that the Syrian children bring disease, which is always said by the doctors. I think these children are healthier than ours. (IN7)

Methods used to keep the child's immune system strong

In our study, the majority of participants stated that they strengthened their children's immune systems by natural methods.

Natural methods/additive-free nourishment

Natural methods are used by parents to boost their children's immunity in Turkey, as in other parts of the world. The reason for the increase in the practice of alternative medicine in recent years is the fact that these issues have been discussed a lot on social media platforms. Parents' commitment and confidence towards vaccination decreased with the increasing preference for natural methods.

In our study, five people thought that natural methods had a positive effect on protecting their children's health:

In the winter, I add bone broth to the food, once a week I provide kelle paça (soup made from sheep's head and feet), I give fish oil and royal jelly, I follow-up the status of vitamin D, I administer oral drops, I apply for a vitamin D analysis... (IN3)

There were also parents who argued that attention should be paid to the nutrition of the child but thought that it was unnecessary to take too many preventive measures. There were parents who said that they paid attention to the natural nutrition:

Takeaway foods never enter my house, which is a plus for me, we consume more vegetables and fruits, which is also a plus. (IN16)

Some of the parents stated that they preferred the herbal methods and some others stated that they did not take any extra precaution:

I apply vinegar I produced at home to the lymph nodes… (IN5)

They are talking about organic food. I no longer believe in organic agriculture because it is not enough to do organic farming in your area alone. What are those irrigation channels next to you? What is the method of irrigation used by others? What is the method of agricultural spraying used by others? These factors also affect your land… (IN15)

Discussion

This study has a number of significant findings. We aimed to present Turkish parents that are hesitant against vaccinating their children and the means by which they decide against one or more vaccines. According to the results of the study, 13 (59%) of the parents did not give their children any vaccination. There are many reasons why parents choose to protect their children from diseases through methods other than vaccines, such as a healthy diet, vitamin supports and preparing special food. One of these reasons is that vaccines are not considered to be safe. According to a systematic analysis of 145 papers published in European Union countries on perceptions of the risk regarding vaccines, vaccine safety was found to be the most important concern about vaccines (Karafillakis and Larson, 2017). As in this study, people mostly blame the preservative substance thiomersal in terms of the vaccine content. Thiomersal is a mercury compound used in eye drops and contact lens solution (Nakayama et al., 1999). However, some parents believe that the vaccine still contains mercury (Burghouts et al., 2017). In light of the detailed research conducted by the WHO General Directorate of Vaccine Safety, in the study of the European Medicines Agency Patented Medical Products Board in March 2004, it was reported that there was no relationship between immunisation with thiomersal-containing vaccines and special neurological development disorders (WHO, 2004). In several studies that have been ongoing for many years, no proven side effects have been found with the use of the dose of thiomersal in vaccines. Thiomersal is usually found in multi-dose vaccines, but not usually in single-dose vaccines. Parents still think that vaccines are unsafe (Sağlık Bakanlığı, 2011).

Some of our participants stated that they believed vaccines were unsafe due to their contents. This is exemplified by the statement of one participant that claimed vaccines contained human semen (IN 5, 9). As vaccines are produced in a chicken embryo fibroblast culture, the measles, mumps and varicella vaccines may contain small amounts (picogram–nanogram) of egg proteins (ovalbumin). These vaccines should be monitored in people who have an egg allergy because some side effects may develop, such as anaphylaxis. In the literature, there are studies suggesting that vaccine administration to children who have an egg allergy should be carried out in a single dose, in two equal doses, or in incremental doses (Freed et al., 2010). Newborn babies have maternal antibodies that protect them from measles and other diseases, but the effects of these antibodies disappear over time and children remain vulnerable until the first vaccination (Burghouts et al., 2017). Although high-dose aluminium has toxic effects, the safe limit level for aluminium content concentration is clearly stated as 2 mg/kg/day. Vaccine-induced aluminium exposure is considerably lower than the amount taken in through the diet. Whereas a 6-month-old baby typically receives approximately 6.7 mg of aluminium with breast milk, this amount reaches 37.8 mg in infant formulas or 116.6 mg in soy-based formulas (Bults et al., 2011).

In 366 children who showed a reaction after measles, mumps and rubella (MMR) vaccine containing 0.2% gelatin, Nakayama et al. (1999) detected 34 instances of anaphylaxis, 76 of urticaria, 215 of non-urticarial rash, and 416 local reactions. We found that our participants came to the conclusion that vaccines were unsafe because of such possibilities (IN 1, 5, 9).

We also had participants who proposed an association between vaccine contents and autism. We observed that autism is one of the main causes of fear among parents (IN 2, 4), despite lack of any evidence to suggest a connection between autism and vaccines. In a retrospective study examining the vaccination and autism status of 537,303 children who were born in Denmark between 1991 and 1998, it was found that there was no difference in terms of the relative risk of autism between those who were administered MMR vaccine and those who were not administered the vaccine. There was no relationship between the time of vaccination and autism development in autistic children (Nakayama et al., 1999).

Several participants indicated they believed vaccines could cause side effects other than autism (IN 2, 3, 9). In a study conducted in Venezuela in 2017, 11 of the 31 parents who participated in the study stated that they were afraid of possible side effects after vaccination. Four of them stated that they were afraid that their children could die due to vaccinations (Burghouts et al., 2017).

Healthcare workers are the key players in preventing vaccine hesitancy. However, distrust of healthcare workers leads to the opposite effect. Some of our participants stated that they preferred not to have their children vaccinated because of their distrust of healthcare workers. Some studies report that this distrust is associated less with healthcare workers and more with the advertisements of vaccine manufacturers (Sari et al., 2017). In a study conducted by ECDC in 2015 to bring together the research and information about vaccine hesitancy and to determine the individual and group effect of vaccine safety on vaccine hesitancy in European countries, it was found that healthcare workers were also negatively affected by vaccine safety; they trusted the healthcare authorities but did not trust the pharmaceutical companies (ECDC, 2015; Nakayama et al., 1999).

According to a systematic review of 145 papers on the risk of vaccines, vaccine safety was found to be the greatest concern (Karafillakis and Larson, 2017). Kata (2010) stated that as a result of the review of anti-vaccination websites, vaccines were refused due to misinformation and various allegations, such as their causing illness, being ineffective, and being against parents' religious beliefs. In our study we had two participants thought that vaccination was haram (forbidden by Islam). A study conducted with 602 mothers in Ankara found that 13.7% of them did not accept the vaccine because they thought it was harmful in Islam (Taşar and Dallar, 2015). In an online study carried out with parents, 11.5% of the respondents refused to give at least one vaccine to their child. In 2017 it was reported that 23,000 families refused to have their children vaccinated in Turkey (Özgenç, 2018).

Immunisation programmes can significantly reduce or even eliminate infectious diseases when administered successfully. However, vaccines are thought to be commercial tricks because they are imported, and there is mistrust in their procurement methods (Bults et al., 2011).

Moreover, there are now outbreaks of COVID-19. This epidemic has affected the whole world. However, according to some conspiracy theorists, this pandemic was also released worldwide for commercial purposes. However, it is also stated that “vaccine hesitant parents” remain silent in this process (Poynter, 2020).

In a survey conducted on Twitter in the United States in 2015, 26,389 tweets about immunisation were reviewed. The majority of these tweets were reported to be about vaccine refusal (Bults et al., 2011; Domek et al., 2018). Various posts on social media platforms, such as ‘the diseases caused by vaccines’, were effective in vaccine refusal (Bults et al., 2011). In a study conducted by ECDC in 2015 to bring together the research and information about vaccine hesitancy, it was found that a single group was not completely hesitant about vaccines (ECDC, 2015), but groups that were hesitant about the vaccines could affect society (Domek et al., 2018). A study conducted in Australia in 2017 examined whether propaganda carried out on social media by the parents who refused the vaccines (in which vaccinated children were called ‘The Unhealthy Other’) had any effect on the masses (Attwell et al., 2018; Sağlık Bakanlığı., 2011).

Vaccines protect not only the child's health, but also the health of society. One of the main aims of vaccination services is to protect the vaccinated individual from the disease; another is to control the disease in society by reaching a certain immunisation rate. A study conducted by Domek et al. (2018) found that 67.8% of the parents who accepted childhood vaccines also stated that it was also important for the health of other individuals. However, public health is affected not only by the immunity of the vaccinated children but also the unvaccinated children. It is important to deal with this problem, especially in the context of Turkey, because of the escalating number of incoming refugees. In 2012, 349 cases of measles were seen in Turkey. It is stated that the number 20 times higher after the increase in the numbers of the Syrian refugees (Sağlık Bakanlığı, 2011). The WHO points out that there are cases of measles, tuberculosis and various infectious skin diseases in Syrians hosted by Turkey, Jordan, Lebanon and Iraq (WHO, 2014a, 2014b). In Kilis, located on the south-eastern border region of Turkey, vaccinations are being administered to children aged 0–59 months to eliminate the risk of polio (Yapıcı and Tunç, 2019).

In a qualitative study including 19 parents and 21 health workers, it was stated that vaccination refusal was higher in regions with a high rate of immigrants. Parents were afraid of irregular migration, and because of this fear, parents did not get the vaccination for their children (Çapanoğlu, 2018). The fact that families do not want to have their children vaccinated despite the increased risk because of the high number of refugees has led them to use alternative protective methods for strengthening the immune system. One study reported that people had more confidence in alternative health practitioners than in vaccinations (Bekis Bozkurt, 2018). A different study from 2017 found that in Australia, families had less confidence in alternative health practitioners compared with vaccines (Yui Kwan Chow et al., 2017). Natural methods or beliefs that natural immunisation is more protective than vaccines have been an important factor in the individual's decision to refuse the vaccine (Bults et al., 2011; Maglione et al., 2014). According to the study conducted by Muhsen et al. (2012) in Israel, it was found that the parents who preferred alternative protection methods had a low vaccination rate for their children. Similarly, in a study conducted with the participation of the healthcare workers, it was found that 40.9% of individuals who did not get the influenza vaccine preferred other prevention methods (Domek et al., 2018).

In a study conducted in Australia, it was observed that those who refused the vaccine resorted to natural methods more frequently (Yui Kwan Chow et al., 2017). In the studies carried out, it has been found that the complementary medicine methods are seen as more natural, non-chemical, side-effect-free and reliable methods that, unlike the large pharmaceutical companies, do not show any concern about making money (Bekis Bozkurt, 2018; Bults et al., 2011; Domek et al., 2018).

Conclusion and suggestions

Childhood immunisation is one of the most important community health practices. Anti-vaccination views have increased rapidly in recent years due to many factors, and public health has become endangered. Therefore, vaccine hesitancy should be examined with a holistic approach.

In this study, we tried to examine parents' general thoughts and perceptions about childhood vaccines in depth. As a result of the interviews, many reasons for vaccine hesitancy were revealed, including how the vaccine-hesitant parents came to prefer alternative protection methods. To sum up, vaccine contents and side effects, sources providing misinformation, religious beliefs, and attitudes of healthcare workers have been some of the reasons that have influenced parents.

One of the important results of this study is that parents are indifferent to the increase in infectious diseases that may be the result of immigration. Parents believe that their children will not be affected by migration. Turkey has seen high rates of immigration in recent years, and it is thought that parents need education about possible epidemics caused by unregistered and unvaccinated refugee children. All immigrants in Turkey need to be officially registered to be able to benefit from medical and social services. Registered Syrian refugees are provided with a temporary identification document. This document is required to use medical and social services. However, approximately one-third of the 4.5 million Syrian refugees are currently unregistered. Therefore, it is vital to explain the possible effects of migration and what causes an increase in the rate of epidemics.

In today's world, where the mass impact of social media cannot be ignored, paediatric and community health nurses play an important role in providing the correct information. Training should be organised in family health centres about the information obtained through social media, and home visits should be made.

It is apparent that vaccine hesitancy in Turkey is influenced by several different reasons. Alternative protection methods are never enough to make up for non-vaccination. Furthermore, because of their lack of immunisation, families fail to protect themselves against diseases brought by refugees. This endangers not only their own children, but also the children of refugees for whom vaccination is sometimes not an option. Therefore, we recommend nationwide pro-vaccination campaigns through all forms of media to reach out to Turkish parents, and the establishment of vaccine counselling call centres as necessary. It is important for experts to answer the questions that families have regarding immunisations.

It is anticipated that there will be a change in the number of parents hesitating about vaccination especially after the COVID-19 outbreak. The question of whether this will be positive or negative should be revealed by future research.

In conclusion, there is a need for further scientific research on vaccination and non-vaccination and studies to increase confidence in immunisation. In the light of scientific data, the education needs of parents should be met, especially after the COVID-19 pandemic. Nurses should provide information about vaccines to parents in health centres where routine childhood vaccinations and follow-ups are given. Furthermore, in order not to be unresponsive to the questions of the public, occupational groups interested in vaccines, such as healthcare workers, physicians, nurses and pharmacists should be provided with in-service training to understand the reasons for anti-vaccination sentiment and to update their knowledge. They can be taught motivational interviewing skills to help parents better understand the truth about vaccines.

Key points for policy, practice and/or research

Parents provided feedback on different ideas about vaccines.

The effect of health workers' attitudes about vaccine hesitation was revealed.

Vaccine-hesitant parents have identified alternative protection methods.

How will parents' views change after the COVID-19 outbreak?

Supplemental Material

sj-pdf-1-jrn-10.1177_1744987120970635 – Supplemental Material for Vaccine-hesitant parents' reasons for choosing alternative protection methods in Turkey

Supplemental Material, sj-pdf-1-jrn-10.1177_1744987120970635 for Vaccine-hesitant parents' reasons for choosing alternative protection methods in Turkey by Aylin Akca Sumengen, Damla Ozcevik, Hulya Yaren Kursun and Ayse Ferda Ocakci in Journal of Research in Nursing

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics

Ethics committee approval was obtained from Koç University Social Sciences Ethics Committee for the research with the decision numbered 2019.066.IRB3.041. The parents were assured that they or their children would not be identified in any way so that parents could easily share their views and experiences with the researcher. Informed consent forms were shared with all participants. Written consents were obtained online.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Aylin Akca Sumengen

Supplemental material

Supplemental material for this article is available online.

Aylin Akça Sümengen: She graduated from Koc University’s nursing college in 2013 and from Koc University’s Institute of Health Sciences in 2016. She is now working as Assistant Professor in Bahcesehir University.

Damla Özçevik: She graduated from Usak University’s nursing college in 2017 and from Koc University’s Institute of Health Sciences in 2019. She is now a PhD student in Koc University.

Hülya Yaren Kurşun: She graduated from Koc University’s nursing college in 2013 and from Koc University’s Institute of Health Sciences in 2016. She now works as a school nurse in College of Bodrum Doga.

Ayşe Ferda Ocakçi: She obtained her bachelor’s degree in 1977 in Hacettepe University, her master’s degree in 1981 and her doctoral degree in 1985 in Hacettepe University Institute of Health Sciences.

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