Abstract
Vaccine hesitancy has, for a considerable time, been a significant risk to global health. As an integral part of disease prevention, vaccines have become a public health matter which is often debated among the community in spite of proven scientific evidence of their efficiency. A questionnaire was designed to evaluate the perception and knowledge of a population and compare it with behavior in order to assess a demographic within a sample population of 245 individuals selected at random within the United States, Here, we aim to clarify the difference between vaccine opinion among the general public as compared to vaccination status. Chi-squared analysis was done with the categorical data showing a statistically significant result when comparing parents versus non-parents, and Asian/Asian Americans against other ethnicities. All other comparisons were statistically insignificant. When looking at participant responses, PCPs did not discuss vaccines at all with 32% of the sample. The need for PCPs to provide educational information to certain ethnicities may play an important role in public health.
Keywords: vaccine education, herd immunity, survey research, attitudes and behaviors, disease prevention and control, immunization compliance
Introduction
Vaccinations are an integral part of preventative medicine and have been used to prevent and at times, eradicate otherwise deadly diseases. There has been a recent movement within this decade to allow non-medical exemptions to vaccinations. 1 Some parents are choosing not to have their children vaccinated or are delaying vaccination for non-medical reasons, which can lead to a loss of herd immunity, 1 the principle by which we manage to keep various historically deadly diseases away.
Although the “vaccine hesitant” behavior may not be indicative of the general population, it raises concerns as to the overall education and basic knowledge of human health within communities.
Living in the age of internet information, many people are relying on blogs, social media posts, and online news articles that are not peer-reviewed by scholarly journals and, therefore, may provide misconceptions about vaccines. 2 As more vaccines are developed, it is important to educate people on the matter. Research has found that there is a need for primary care physicians to educate parents on vaccinations; if individuals are not properly informed about risks such as allergies, it can cause an unnecessary delay in vaccination or promote misconceptions, a concept which is particularly relevant to the pediatric population. 3
Vaccine hesitancy made the top 10 list of global health threats of 2019, making understanding what causes individuals not to vaccinate when it is available a primary goal. Divulgement of false or misleading information has fomented distrust and misunderstanding within the healthcare system when approaching the subject of vaccines. A commonly cited example of this is the 1998 paper on autism by Dr. Andrew Wakefield, which was redacted due to fraudulent practices. 4 Healthcare providers should be the most important advisors when it comes to delivering information which directly impacts the health of patients. Competent and well-informed individuals make better assessments and decisions when a healthcare professional is involved. It was observed that general practitioners are not practicing due diligence when it comes to keeping up with patients’ vaccinations, nor are they clearly and concisely informing patients about the risks and benefits of vaccines. 3
The concept of herd immunity requires at least 95% compliance to be effective in the population. 5 When this compliance is not met, there is a threat to the status of public health. In the field of medicine, herd immunity is characterized by a decreased susceptibility to a given disease among newborns or individuals who are unable to receive vaccination due to immunocompromised status, when residing in a population that is immune to the disease. 5 In other words, individuals with weak immune systems are unable to reap the benefits of vaccination and often depend on their communities to help protect them by being vaccinated. An understanding of herd immunity could play an important gauge in assessing the awareness of the population regarding the schedules implemented by government agencies and scientific/clinical reference centers.
An increase in compliance could help decrease the incidence of some diseases through new vaccination programs. For example, there have been studies that evaluate newer vaccine programs like HPV. 6 It has been noted that female vaccination would reduce cervical cancer cases by 61.8% and was cost-effective. 7 They also determined that males being a vector for HPV, could be immunized, reducing the incidence of cancer by 2.2% by enhancing herd immunity but was deemed cost-ineffective compared to a female-only model. The study shows that HPV vaccination should be given at the age of 12 years and to females only if resources are scarce, and this can only occur if families are compliant, but we can see the potential in preventative medicine. 7 Our objective here is to assess general opinion and knowledge regarding vaccines among the adult population (>18 years of age) and contrast them with the vaccination status of both adults and their children.
Materials and Methods
A cross-sectional study was conducted using surveys to assess attitude, depth of factual knowledge, and applied behaviors regarding vaccines. All participants in the study gave written consent and agreed to confidentiality and anonymity terms in order to complete the questionnaire. The questionnaire was the same for all participants; participants with no children were instructed to leave the respective sessions blank so as not to alter the subsequent calculations. The questionnaire was distributed through social media platforms, including, but not limited to Facebook and WhatsApp between May 1st 2019 and August 1st 2019. The sample of the population was taken using convenience sampling from the general US population. No upper limit was given for the size of the sample. It was divided into 3 parts: Demographics, Awareness, and Compliance. The survey was performed through Survey Monkey and approved by an institutional research committee review board. The questionnaire in its entirety can be found in Appendix A and was formulated by the researchers.
The demographics section of the questionnaire included all questions related to the population and groups of interest. The awareness section included questions related to an individual’s personal knowledge of how vaccines are used, how they prevent disease, and the side effects associated with vaccines. This section also included how individuals receive information about vaccines. The compliance section inquired regarding vaccine adherence, with questions featuring vaccine guideline compliance, reasons for being non-compliant, fear of compliance, and patient’s relationship with their primary care provider. All collected data were analyzed using chi-square statistical analysis.
A total of 245 individuals from across the US responded online. The nominal data was then given a system of numerical values depending on the response to the questions on the questionnaire. After compiling responses, a chi-square statistical analysis was done to assess whether a relationship existed between categorical variables. If the variables were independent of each other, the chi-square analysis was insignificant (P > .05 at a confidence level of 95%).
Results
After data collection, a chi-squared analysis, as well as an analysis of individual questions was performed (Appendix B). The chi-square analysis of parents versus non-parents was significant for “Do you believe vaccines are effective?” (P = .022). The chi-square analysis of ethnicity was significant for Asian/Asian Americans when responding to “Do you believe vaccines are safe?” (P < .001) and “Do you believe vaccines are effective?” (P < .001). Figures 1 and 2 show this data in comparing all other ethnic group responses to vaccine effectiveness and safety belief. Figure 3 compares the proportion of parents to non-parent response to vaccine effectiveness belief.
Figure 1.
Proportion of ethnic groups that answered “yes” they believed vaccines are safe. This gave a chi-square value of 10 to 8, which is significant for the Asian/Asian American population that believed vaccines are less likely to be safe when compared to other ethnic groups.
Figure 2.
Proportion of ethnic groups that answered “yes” they believe vaccines are effective. This gave a chi-square test value of 10 to 9 that was significant for Asian/Asian American populations when asked if they believed vaccines to be effective.
Figure 3.
Proportion of parents versus non-parents that answered “yes” they believed vaccines are effective. This gave a P-value of .02 from the chi-square test, which is significant (P < .05).
Other analyses comparing genders to responses to the questions “Do you believe vaccines are safe?” and “Do you believe vaccines are effective?” were insignificant, P-value (P = .737 and .2, respectively). Analysis comparing level of education also was insignificant for the same 2 questions mentioned above, P-value (.263 and .383, respectively). All other analyses comparing the different demographic categories to responses did not show a statistically significant result. It was observed that in a statistically significant fashion, parents were more likely to be “vaccine hesitant” as compared to non-parents but were still up to date with their own vaccines. Asian/Asian American individuals were less likely to believe vaccines were safe and effective; when analyzing the responses, they made up the majority of unvaccinated participants (38.8%).
When comparing responses to individual questions in the awareness and compliance section of Appendix B, it was noted that 32% responded “not at all” when asked about their Primary Care Provider (PCP) discussing vaccinations; of those participants, 87.7% were up to date on their vaccinations.
Discussion
Out of the 8 Chi-square analyses performed, 3 showed statistical significance. It was observed that regarding parents versus non-parents; parents were more likely to question the effectiveness of vaccines and respond “no” to the prompt directly asking whether they thought vaccines were effective. Of note, the parents that did not believe that vaccines were effective still had chosen to practice vaccinating their children, within our study 87.6% of these participants had vaccinated children. These findings are consistent with a recent study which showed that parents favor vaccinations as a necessity in practice even though they lack the understanding of how they work. 8
Our research encompassed individuals from various cultures and ethnicities. The data within our study showed that individuals who identified as Asian and/or Asian American were more likely to believe vaccines are unsafe and ineffective compared to other ethnic groups, see Figures 1 and 2. Out of the participants, 18 said they were not up to date on their vaccinations, and out of those participants 38.8% identified as Asian and/or Asian American; 14 participants were unsure of their vaccination status, and out of those participants, Asian and/or Asian Americans comprised 35.7%. This shows that targeting the Asian American population with educational material in the language they are most comfortable with will make it more clear to them the importance of getting vaccinated and help diminish barriers due to misinformation about vaccines.
Regarding education level, 46% of participants had already received a bachelor’s degree. This indicates that our sample has a high level of educational background but it did not affect the responses to questions in both awareness and knowledge. An individual’s personal beliefs was not the driver of vaccine hesitancy but a lack of education in that specific topic of vaccines regardless of background may be the more concerning culprit. A respondent did not need to have a high level of education or know every adverse reaction to vaccines to make reasonable decisions, as discussed below.
In general, most responders (54% of participants) stated receiving their information regarding vaccinations from their primary care provider (PCP). Even though most of this information is coming from a medical professional, it was also noted that the subject was not touched upon on a regular basis. As evidence of this, 49% of the responders stated that their PCP had “somewhat” discussed vaccines with them, and 32% responded that their PCP had not discussed vaccinations with them at all. This is in line with a study which featured how the importance of the information provided is related to an individual’s compliance toward and understanding of vaccines. This study found that the lack of information and involvement of PCP were leading to substantial delays in children receiving the MMR vaccines, causing an increase in outbreaks throughout Poland. 3 A primary care provider’s duty first and foremost, is to practice preventive medicine whenever possible. This study has observed that there is a significant lack of communication between our responders and their PCPs on the subject of vaccinations, which are a significant tool in the prevention of disease.
Regarding the question: “Do you believe individuals with weakened immune systems are unable to receive vaccinations?” Within the responders, 34% were “not sure” as to whether vaccines can be given to immunocompromised individuals and 40% responded “no, immunocompromised individuals are unable to receive vaccinations.” It is of note that many immunocompromised individuals can receive vaccinations depending on the vaccine. Immunocompromised individuals are unable to receive live-attenuated vaccines but can receive other types at the discretion of their providers. These vaccines will generally be less effective and patients are assessed on a case-to-case basis. 7 Respondents did not need to know the answer to this question, the lack of knowledge of specific indications for vaccines is more of a reason that the population should receive guidance from health-care providers. An open-discussion of the vaccine schedule, adverse effects, and indications for vaccination is best done in the physician’s office to clear any misconceptions and make informed decisions. 7
The need for PCPs to provide insightful and educational information regarding topics such as immunocompromised patients, safety, and effectiveness related to vaccines is unequivocally important in preventing the spread of diseases amongst the population. 3 An overall increased understanding of vaccines would help mitigate the global threat that is posed by vaccine hesitancy and increase compliance, thus improving public health.
Recommendations and Conclusion
Vaccine hesitancy is a significant threat to public health; this study aimed to better assess this behavior in an effort to continue to provide data regarding the matter. As tools of disease prevention, it was noted that it is important for healthcare professionals to initiate and follow up on conversations regarding vaccines to better educate patients within our communities. Subjects such as immunocompromised patient safety, the safety of vaccines, and their effectiveness are recommended matters of discussion for these interactions. Future research may document and analyze additional data including socioeconomic status and its relation to vaccine awareness, hesitancy, and compliance. It is the healthcare provider’s duty to properly divulge information and promote awareness of matters regarding public health through this investigation. It is our aim to raise awareness of the fact that a better effort toward educating patients may be performed with the goal of improving overall public health.
Limitations
The authors acknowledge that there were limitations to this research. The population sample was limited to 245 participants using convenience sampling. In the future, a larger sample size is recommended for improved validity. Convenience sampling was utilized, limiting the demographics of the questionnaire; this was due to the use of participants from the researcher’s social media accounts (WhatsApp and Facebook). In addition, the utilization of stratified random sampling that better resembles the global population would be of interest in the future. It is of note that in spite of the limitations, all data was legally obtained and treated with the highest level of confidentiality, and our findings were herein truthfully reported to the best of our abilities.
Appendix A
Participation Consent Form
This is a simple survey with no right or wrong answers. Participant’s name and/ or any personal details will be held under strict confidentiality norms and standards ensuring of utmost privacy to the individual’s voluntary participation for the study. This survey looks at the general populations awareness and compliance with the current CDC vaccination schedule which is administered from birth to 15 months. The survey is completely voluntary and answers will be anonymous and seen only by the researchers. By participating in this study, you agree that all of your answers are honest and true. Please complete the questions on the survey to the best of your ability. This study starts off with some personal demographic questions which must be answered for completion of this survey. You may exit out the survey at any point if you wish to do so. Those who choose not to complete the entire survey will be excluded from research and any completed questions will be discarded. Permission is required to use research data from this survey toward the researcher’s publication on this topic. You must be 18 years or older to complete this study. Data collection is managed by SurveyMonkey. Please review their Privacy Policy to better understand how your information is collected, secured, and managed. By answering “I Agree” below you consent to the information in the survey being used for research analytics, you confirm that you are 18 years of age or older, and that you agree to the terms as described above
I agree to participate voluntarily to the survey as explained above and offer my consent to use the data obtained by the researchers for scientific/analytical or publication purposes. Use, and terms listed above.
I agree with and understand the terms of the study_______________________ X signature
Date: _______________________
Questionnaire
Please tick (√) appropriately:
- (1) Demographics
- 1. What is your biological sex?
Male Female - 2. What is your age?
18-24 years 25-34 years 35-44 years 45-54 years 55+ years - 3. Are you currently or have you ever been the parent or guardian to a child?
Yes No - 3b. If you answered “Yes” to the question above, how many children do you have?
1-2 3-4 5+ N/A - 4. What is your race/ethnicity?
Caucasian Black/African Latino/Hispanic Asian/Pacific Islander Native American Other Prefer not to answer - 5. What is the highest level of formal education you have attained?
Less than high school diploma High school diploma or equivalent Bachelor’s degree (BA/BS) Masters degree (MA/MS, MED) Doctorate (PhD, MD) Other (please specify) Prefer not to answer - 6. What is your marital status:
Single, never married Married Domestic partnership Divorced Widowed Prefer not to say
- (2) Awareness
- 1. Do you believe vaccines are effective?
Yes No Not sure - 2. Do you believe vaccines are safe?
Yes No Not sure - 3. Where do you generally receive MOST of your information on vaccination?
Social media/blogs (Facebook, twitter, Tumblr etc. . .) News/news articles (TIME, Newsweek, USA Today, FOX, CNN, etc. . …) Scientific literature (Google Scholar, Pub Meb, etc. . . .) Your primary care provider (MD, DO, PA, and NP) From your peers Other (please specify) - 4. Do you have a general understanding of the use, method of administration and the importance vaccination?
Yes No - 5. Are you aware of any of the possible side-effects/complications caused by vaccines?
Yes No Not sure - 6. Do you believe that there is evidence that vaccines cause autism?
Yes No Not sure - 7. Do you believe vaccines have a high risk for possible serious side-effects?
Yes No Not sure - 8. Do you believe vaccines are safe?
Yes No Not sure - 9. Do you believe vaccines contain harmful amounts of mercury?
Yes No Not sure - 10. Do you believe individuals with weakened immune systems are unable to receive vaccines?
Yes No Not sure - 11. Do you believe the number of vaccines given from birth to 15 months may cause health problem in children?
Yes No Not sure
- (3) Compliance
- 1. As a parent/guardian are your children currently up to date on the recommended vaccinations?
Yes No Not sure - 2. Do your fears of possible side effects of vaccines influence your decision to get vaccinated?
Yes No Not sure Prefer not to say - 3. How often does your doctor discuss vaccinations with you?
Often Somewhat Not at all - 4. As a parent/guardian or prospective parent/guardian, would you follow guidelines on vaccinations for your child in your country?
Yes No Not sure Prefer not to say - 4b. If you answered “No” to the previous question, why would you choose not to follow the recommended vaccination guidelines of your country?
Someone you personally know has had an adverse reaction to a vaccine You have heard of someone that has had an adverse reaction to a vaccine You have been told vaccines are harmful by peers You have been informed via media/social media that vaccines are harmful Your primary care provider or a medical professional (MD, DO, PA, and NP) informed you vaccines are harmful I believe vaccines are not efficient Religious reasons Other (please specify)
Appendix B.
Demographics.
| 18-24 | 25-34 | 35-44 | 45-54 | 55+ | |
| What is your age? | 32.65% | 35.10% | 11.84% | 11.43% | 8.98% |
| Children | No Children? | ||||
| Are you currently or have you ever been the parent or guardian to children? | 44.90% | 53.88% | |||
| 1-2 | 3-4 | 5+ | |||
| If answered “YES” to previous question, how many children do you have? | 52.73% | 33.64% | 13.64% | ||
| White/Caucasian | Asian/Asian American | Black/African American | Other | ||
| What is your race/ethnicity? | 64.08% | 20.00% | 3.27% | 12.65% | |
| High school/GED | Some college | Associates degree | Bachelor’s degree | Masters/PhD | |
| What is the highest level of formal education you have attained | 31.43% | 0 | 0 | 43.67% | 24.90% |
| Single, unmarried | Married | Divorced | Widowed/other | ||
| What is your marital status? | 46.53% | 34.69% | 8.57% | 10.20% | |
Awareness.
| Yes | No | Unsure | ||||
| Do you believe vaccines are safe? | 85.31% | 2.45% | 12.24% | |||
| Yes | No | Unsure | ||||
| Do you believe vaccines are effective? | 91.02% | 1.63% | 7.35% | |||
| Social media/blogs (Facebook, etc.) | News/articles (TIME, USA Today, FOX, etc.) | Scientific literature (Pub Med, etc.) | Primary care provider (MD, DO, etc.) | Peers | Other | |
| Where do you generally receive MOST of your information of vaccinations? | 8.57% | 11.43% | 20.41% | 53.47% | 3.67% | 2.45% |
| Yes | No | Unsure | ||||
| Do you have a general understanding of the use, method of admin and the importance of vaccines? | 91.42% | 3.27% | 5.31% | |||
| Yes | No | Unsure | ||||
| Are you aware of any of the possible side-effects/complications caused by vaccines? | 71.43% | 11.43% | 17.14% | |||
| Yes | No | Unsure | ||||
| Do you believe that there is evidence that vaccines cause autism? | 5.71% | 71.43% | 22.86% | |||
| Yes | No | Unsure | ||||
| Do you believe vaccines have a high risk for possible serious side-effects? | 13.06% | 62.45% | 24.49% | |||
| Yes | No | Unsure | ||||
| Do you believe vaccines contain harmful amounts of mercury? | 3.27% | 63.27% | 33.47% | |||
| Yes | No | Unsure | ||||
| Do you believe individuals with weakened immune systems are unable to receive vaccines? | 25.31% | 37.55% | 37.14 | |||
| Yes | No | Unsure | ||||
| Do you believe the number of vaccines given from birth to 15 months can cause health problems? | 6.12% | 67.35% | 25.53% | |||
Compliance.
| Yes | No | Unsure | ||||||
| Are you currently up to date with the recommended vaccinations? | 82.04% | 6.94% | 11.02% | |||||
| Yes | No | Unsure | ||||||
| As a parent/guardian, are your children currently up to date on the recommended vaccinations? | 80.91% | 6.36% | 12.73% | |||||
| Often | Somewhat | Not at all | ||||||
| How often does your doctor discuss vaccinations with you? | 18.37% | 49.80% | 31.84% | |||||
| Yes | No | Unsure | ||||||
| As a parent/guardian or prospective parent/guardian would you follow guidelines on vaccinations for your children in the US? | 62.86% | 2.04% | 35.10% | |||||
| Someone you know had an adverse reaction | You’ve heard of someone who has had an adverse reaction | You’ve been told vaccines are harmful by peers | You have been informed by social media that vaccines are harmful | Your primary care provider informed you vaccines are harmful | I believe vaccines are not effective in preventing disease | Religious reasons | Other | |
| If you answered “NO” to the previous question why would you choose not to follow he recommend-ed vaccination guidelines? (check all that apply) | 20.00% | 60.00% | 0 | 0 | 20.00% | 0 | 0 | 0 |
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Mohamad Dimassi 
https://orcid.org/0009-0009-8623-3801
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