ABSTRACT
Meningococcal infections range from asymptomatic carriage to fulminant sepsis with tissue necrosis. As the disease progresses rapidly, vaccination remains the most effective preventive strategy. Parental acceptance of vaccination is closely linked to awareness, knowledge, attitudes, and behaviors. This study explores these factors and offers targeted recommendations to enhance vaccine uptake. This cross-sectional, descriptive, and comparative study was conducted via a questionnaire administered to parents of pediatric patients seen or hospitalized at the University of Health Sciences Haydarpaşa Numune Training and Research Hospital. The survey assessed socio-demographic characteristics, awareness and knowledge of meningococcal infections and vaccines, and vaccination-related attitudes and behaviors. A total of 306 parents participated voluntarily. Of the 306 participating parents, 257 (84%) were mothers and 49 (16%) were fathers.Only 71 parents (23.3%) were aware of meningococcal infections and vaccines, and just 29 (9.5%) had their child vaccinated. Among those aware of the vaccine, the main reasons for non-vaccination were lack of recommendation from their family physician (57.1%), insufficient knowledge about side effects (54.8%), and exclusion from the national immunization program (52.4%). The low rate of vaccine acceptance among parents is primarily attributed to their limited awareness of meningococcal diseases and vaccines. Therefore, public health authorities – particularly the Ministry of Health – should implement organized vaccination awareness campaigns through media and social networks to enhance public knowledge and increase awareness levels.
KEYWORDS: Neisseria meningitidis, meningococcal infections, meningococcal vaccines, parents, behavior
Introduction and objective
Meningococcal infections range from asymptomatic carriage to severe sepsis and fulminant meningococcemia with tissue necrosis. Neisseria meningitidis typically colonizes the nasopharynx and spreads via respiratory droplets or saliva during close contact.1–3
Despite declining incidence, meningococcal epidemics persist in the meningitis belt. Vaccination is the most effective protection against this rapidly progressing disease.4 MenACWY vaccines have long been used in the U.S., while MenB vaccines were first licensed in 2014.5
Although meningococcal disease incidence and mortality have declined in our country, it still accounts for 9.5% of deaths in children under five.6 Despite its public health importance, prophylactic vaccines remain optional and are not yet included in the national immunization program (NIP).
The primary objectives of this study were to: (1) assess parental knowledge and awareness of meningococcal infections and vaccines; (2) determine the meningococcal vaccination rate and associated factors; and (3) evaluate the impact of a structured educational intervention on parental vaccine acceptability.”
Materials and methods
Study design
The study was initiated following the approval of the Clinical Research Ethics Committee of the University of Health Sciences Haydarpaşa Numune Training and Research Hospital (09.03.2020; HNEAH-KAEK 2020/33) and was conducted in accordance with the ethical principles of the Declaration of Helsinki, including its subsequent revisions.
This study is a cross-sectional, descriptive, and comparative survey designed to evaluate parents’ knowledge, attitudes, and behaviors regarding the meningococcal vaccine.
The study was conducted with the parents of patients who presented to the Pediatric Outpatient Clinic or were hospitalized in the Pediatric Department of the University of Health Sciences, Istanbul Provincial Health Directorate, Haydarpaşa Numune Training and Research Hospital, and who provided written informed consent.
Data collection tool
A structured 44-item questionnaire was specifically developed for this study to assess parents’ sociodemographic characteristics, awareness, knowledge, and attitudes regarding meningococcal disease and vaccination. As no validated instrument covering all relevant domains was available, the questionnaire was developed de novo, with several items conceptually adapted from previously published surveys.
The questionnaire was developed de novo by the authors, with items conceptually anchored in key constructs from health behavior models (e.g., the Health Belief Model) and themes identified in prior literature on vaccine hesitancy. The instrument was pilot-tested on 20 parents to assess face validity, comprehensibility, and flow. Minor wording adjustments were made based on feedback.The knowledge section consisted of independent factual items addressing transmission, risk groups, symptoms, and vaccine availability. Since these items were not designed to measure a single construct, internal consistency analyses (such as Cronbach’s alpha) were not applicable, and knowledge results were reported item-by-item.
The attitude items covered heterogeneous aspects of parental decision-making, including perceived need for vaccination, safety concerns, and financial considerations; therefore, these items also did not form a unidimensional scale. The complete list of knowledge and attitude items has been provided in the supplementary material (Supplementary File 1).
The question regarding reasons for non-vaccination was asked only to parents whose children had not received the meningococcal vaccine. Multiple responses were allowed for this item, as parents could identify more than one perceived barrier. Therefore, the percentages reported for each reason reflect the frequency of selection rather than mutually exclusive categories.
Statistical analysis of the data
Data were analyzed using IBM SPSS Statistics 22 (Turkey). Normality was tested with the Shapiro – Wilk test. Categorical variables were presented as frequencies and percentages. Comparisons between categorical variables were performed using the Chi-square test or Fisher’s Exact test, as appropriate. Continuous variables were summarized as mean ± standard deviation or median (interquartile range), depending on distribution. Student’s t-test and One-Way ANOVA were used for normally distributed data, while the Mann – Whitney U test was applied for non-normally distributed variables.
Pearson or Spearman correlation analyses were conducted according to data distribution. p < .05 was considered statistically significant.
Internal consistency analyses (such as Cronbach’s alpha) were not performed, as the knowledge items assessed factual information rather than a unidimensional latent construct.
Results
Participant characteristics
The study was conducted between May 1, 2020, and June 30, 2020, with a total of 306 parents, including 257 (84%) mothers and 49 (16%) fathers. The mean age of the parents was 35.53 ± 7.05 y, and the mean age of their children was 7.3 ± 5.08 y (Table 1).
Table 1.
Distribution of general characteristics.
| Min–Max | Mean ± SD | ||
|---|---|---|---|
| Child’s age | 0.17–17 | 7.3 ± 5.08 | |
| Parent’s age | 18–56 | 35.53 ± 7.05 | |
| Number of children (median) | 1–5 | 2.22 ± 0.91 (2) | |
| n | % | ||
| Parental role | Mother | 257 | 84 |
| Father | 49 | 16 | |
| Parental occupation | Unemployed | 193 | 63.1 |
| Civil servant | 26 | 8.5 | |
| Healthcare worker | 17 | 5.6 | |
| Other | 70 | 22.9 | |
| Parental education level | None | 11 | 3.6 |
| Primary school | 101 | 33 | |
| Middle school | 54 | 17.6 | |
| High school | 79 | 25.8 | |
| University | 51 | 16.7 | |
| Postgraduate/PhD | 10 | 3.3 | |
| Total monthly family income | Less than minimum wage(MW) | 24 | 7.8 |
| MW | 105 | 34.3 | |
| 2*MW | 92 | 30.1 | |
| 3*MW | 51 | 16.7 | |
| >3MW | 34 | 11.1 |
Regarding parental education levels, 11 (3.6%) were illiterate, 101 (33%) had completed primary school, 54 (17.6%) middle school, 79 (25.8%) high school, 51 (16.7%) university, and 10 (3.3%) held a master’s or doctoral degree. To enable more robust group comparisons, these education levels were categorized into four groups: illiterate, primary/middle school graduates, high school graduates, and university/postgraduate degree holders (Table 1).
An analysis of monthly household income levels revealed that 24 families (7.8%) had an income below the minimum wage (MW), 105 families (34.3%) had an income equivalent to 1 MW, 92 families (30.1%) approximately 2 MW, 51 families (16.7%) approximately 3 MW, and 34 families (11.1%) had an income exceeding 3 MW (Table 1).
Parents’ awareness of meningococcal infections and vaccines, and information sources
Only 71 parents (23.2%) were aware of meningococcal infections. Among those who were aware, 19 parents (26.8%) had received information from family physicians, 36 (50.7%) from pediatricians, 17 (23.9%) from other healthcare professionals, 19 (26.8%) from media sources such as the Internet, television, newspapers, or magazines, and 24 (33.8%) from acquaintances (Table 2).
Table 2.
Awareness of meningococcal infections and vaccines, and distribution of sources of information.
| n | % | ||
|---|---|---|---|
| Awareness of meningococcal infections | Yes | 71 | 23.2 |
| No | 235 | 76.8 | |
| Source of information about meningococcal infections (n = 71)* | From family physician | 19 | 26.8 |
| From pediatrician | 36 | 50.7 | |
| From other healthcare personnel | 17 | 23.9 | |
| Internet/TV/Newspaper/Magazine | 19 | 26.8 | |
| Acquaintances in the community | 24 | 33.8 | |
| Awareness of meningococcal vaccines | Yes | 71 | 23.2 |
| No | 235 | 76.8 | |
| Source of information about meningococcal vaccines (n = 71)* | From family physician | 23 | 32.4 |
| From pediatrician | 37 | 52.1 | |
| From other healthcare personnel | 20 | 28.2 | |
| Internet/TV/Newspaper/Magazine | 20 | 28.2 | |
| Acquaintances in the community | 19 | 26.8 |
*Multiple responses were allowed.
Seventy-one parents (23.2%) had heard of meningococcal vaccines. Among them, information sources included pediatricians (52.1%), family physicians (32.4%), other healthcare professionals (28.2%), media (Internet, television, newspapers, or magazines) (28.2%), and acquaintances (26.8%)(Table 2).
Status of meningococcal vaccination and reasons for non-vaccination
Among the parents who participated in the survey, 29 (9.5%) had their child vaccinated against meningococcal disease, while 277 (90.5%) had not. An analysis of the reasons for non-vaccination revealed that 23 parents (8.3%) cited lack of knowledge about vaccine side effects, 256 (92.4%) stated that they had not been informed by a pediatrician, and 259 (93.5%) reported not being informed by a family physician. Additionally, 9 parents (3%) indicated the vaccine was too expensive, 16 (5.8%) said they did not find it reliable, 4 (1.4%) believed it to be harmful, 25 (9%) noted that it is not included in the NIP, 1 (0.4%) declined due to religious beliefs, and 13 (4.7%) cited other reasons (Table 3).
Table 3.
Parents’ meningococcal vaccination status for their children, reasons for non-vaccination, and vaccination rates among those aware of the vaccine.
| N | % | ||
|---|---|---|---|
| Vaccination status of the child with meningococcal vaccine | Yes | 29 | 9.5 |
| No | 277 | 90.5 | |
| Reasons for not vaccinating the child (n = 277)* | I don’t know the side effects of the vaccine | 23 | 8.3 |
| I was not informed by my pediatrician | 256 | 92.4 | |
| I was not informed by my family physician | 259 | 93.5 | |
| The vaccine was expensive | 9 | 3.2 | |
| I did not find it reliable | 16 | 5.8 | |
| I believe it is harmful | 4 | 1.4 | |
| It is not included in the national immunization program | 25 | 9 | |
| Due to my religious beliefs | 1 | 0.4 | |
| Other reason for not vaccinating | 13 | 4.7 | |
| Vaccination status among those who had heard of the vaccine (n = 71) | Yes | 29 | 40.8 |
| No | 42 | 59.2 |
*Note: Percentages are calculated based on the number of respondents who could select multiple reasons; therefore, the sum of percentages exceeds 100%.
Among the group who had heard of the meningococcal vaccine, 29 parents (40.8%) had their child vaccinated, while 42 (59.2%) had not (Table 3).
Parental education levels and household income were found to be significantly associated with meningococcal vaccination rates. The vaccination rate was significantly higher among parents with a university or postgraduate degree (31.1%; p = .025) compared to other education groups. Similarly, the highest income group had a significantly higher vaccination rate than the other income groups (52.9%; p < .001) (Table 4).
Table 4.
Evaluation of the relationship between socio-demographic characteristics and the child’s meningococcal vaccination status.
| Meningococcal Vaccination Status of the Child |
P | |||
|---|---|---|---|---|
| Yes | No | |||
| Mean ± SD (median) | Mean ± SD (median) | |||
| Number of children(Median) | 1.93 ± 0.8 (2) | 2.25 ± 0.92 (2) | a.053 | |
| Number of people living in the household(Median) | 4.03 ± 0.91 (4) | 4.43 ± 1.25 (4) | a.101 | |
| Parent’s age | 36.72 ± 6.27 | 35.4 ± 7.12 | b.337 | |
| n (%) | n (%) | |||
| Parental role | Mother | 24 (%9.3) | 233 (%90.7) | c.510 |
| Father | 5 (%10.2) | 44 (%89.8) | ||
| Parental occupation | Unemployed | 8 (%4.1) | 185 (%95.9) | d.000* |
| Civil servant | 7 (%26.9) | 19 (%73.1) | ||
| Healthcare worker | 6 (%35.3) | 11 (%64.7) | ||
| Other | 8 (%11.4) | 62 (%88.6) | ||
| Parental education level | None | 0 (%0) | 11 (%100) | e.000* |
| Primary/Middle school | 5 (%3.2) | 150 (%96.8) | ||
| High school | 5 (%6.3) | 74 (%93.7) | ||
| University/Postgraduate/PhD | 19 (%31.1) | 42 (%68.9) | ||
| Monthly total household income | <1*MW | 1 (%4.2) | 23 (%95.8) | d.000* |
| 1*MW | 2 (%1.9) | 103 (%98.1) | ||
| 2*MW | 5 (%5.4) | 87 (%94.6) | ||
| 3*MW | 3 (%5.9) | 48 (%94.1) | ||
| >3*MW | 18 (%52.9) | 16 (%47.1) | ||
aMann–Whitney U test bStudent’s t-test cFisher’s exact test dFisher–Freeman–Halton test eChi-square test *p < .05, MW: Minumume Wage, SD: Standard Deviation.
A statistically significant proportion of individuals who had heard of meningococcal vaccines had a higher level of education (35/71 [57.4%]; p = .001) and belonged to the highest income group (28/71 [82.4%]; p < .001). Additionally, the rate of awareness of meningococcal vaccines was significantly higher among healthcare worker parents compared to other occupational groups (13/71 [76.5%]; p = .033).
Willingness to vaccinate after being informed about meningococcal infections and vaccines
Parents who had not vaccinated their children were asked whether they would consider vaccination after receiving information about meningococcal infections and vaccines. Following the information session, 95 parents (34.3%) stated they would consider vaccination, 79 (28.5%) said they would not, and 103 (37.2%) were undecided (Table 5).
Table 5.
Parents’ willingness to have their child vaccinated after receiving information about meningococcal infections and vaccines, and distribution of reasons for refusal.
| N | % | ||
|---|---|---|---|
| Willingness to Vaccinate After Information | Yes | 95 | 34.3 |
| No | 79 | 28.5 | |
| Undecided | 103 | 37.2 | |
| Reasons for Refusal After Information (n = 182)* | I think it is too expensive | 138 | 75.8 |
| I’m afraid of possible side effects | 69 | 37.9 | |
| I don’t think it is necessary | 21 | 11.5 | |
| Because it is not included in the national immunization program | 74 | 40.7 | |
| Due to my religious beliefs | 2 | 1.1 | |
| Other reasons | 1 | 0.5 |
*Note: Percentages are calculated based on the number of respondents who could select multiple reasons; therefore, the sum of percentages exceeds 100%.
An analysis of the reasons for unwillingness or indecision after the information session revealed that 138 parents (75.8%) cited the high cost of the vaccine, 74 (40.7%) stated that it is not included in the Ministry of Health’s national immunization program, and 69 (37.9%) expressed fear of potential side effects (Table 5, Figure 1).
Figure 1.
Top reasons for meningococcal vaccine refusal after the informational session.
Status of receiving non-meningococcal paid vaccines
Parents’ acceptance of other non-meningococcal paid vaccines was analyzed to examine its association with meningococcal vaccination status.Therefore, a comparative analysis was conducted between parents who had previously accepted at least one other paid vaccine and those who had not. The proportion of parents who had accepted other paid vaccines was significantly higher among those who had heard of the meningococcal vaccines compared with those who had not (42.3% vs. 14.5%, p < .001). Likewise, parents who had vaccinated their children against meningococcal disease were significantly more likely to have accepted other paid vaccines than those who had not vaccinated their children (65.5% vs. 16.2%, p < .001) (Table 6).
Table 6.
Assessment of the relationship between acceptance of other paid childhood vaccines and meningococcal vaccine awareness and uptake.
| Acceptance of other paid vaccines for the child |
P | ||
|---|---|---|---|
| Yes | No | ||
| n (%) | n (%) | ||
| Meningococcal Vaccine Awareness | |||
| Yes | 30 (%42.3) | 41 (%57.7) | a.000* |
| No | 34 (%14.5) | 201 (%85.5) | |
| Meningococcal vaccination status of the child | |||
| Yes | 19 (%65.5) | 10 (%34.5) | b.000* |
| No | 45 (%16.2) | 232 (%83.8) | |
aChi-square test, bContinuity (Yates) correction, *p < .05.
A total of 64 parents (20.9%) had their child receive at least one paid vaccine other than the meningococcal vaccine, while 242 (79.1%) had not. Among the non-meningococcal vaccines administered, 52 (81.3%) were rotavirus vaccines and 19 (29.7%) were influenza vaccines.
Discussion
This study provides important insights into parental knowledge, attitudes, and acceptability of meningococcal vaccination in Türkiye, where the meningococcal vaccine is not included in the national immunization program. The most striking findings include the very low baseline awareness of meningococcal disease and vaccines (23.2%), the low vaccination rate (9.5%), and the substantial increase in willingness to vaccinate following a brief physician-delivered educational intervention (from 9.5% to 31%). In addition, physician recommendation emerged as a critical determinant of vaccination behavior, while vaccine cost remained the dominant barrier even after parents received structured information. Taken together, these findings highlight both the magnitude of the unmet need and the potential effectiveness of targeted educational strategies.
Our findings are consistent with international literature demonstrating that physician recommendation is one of the strongest determinants of parental vaccine acceptance.7 In countries where meningococcal vaccines are included in routine immunization schedules, parental awareness and vaccination coverage are substantially higher, reflecting the combined impact of national policy and consistent healthcare provider messaging.8,9 In contrast, in settings where meningococcal vaccination is optional or self-funded, awareness and uptake remain considerably lower.10,11 Notably, our results closely align with findings from Türkiye reported by Çelik and Şahbaz (2022), who observed similarly low awareness levels for meningococcal disease and non-routine childhood vaccines, suggesting that this challenge is systemic rather than region-specific.12
The analysis of barriers to vaccination identified cost, non-inclusion of the vaccine in the national immunization program, and persistent safety concerns as the principal drivers of vaccine hesitancy. Socioeconomic disparities played a central role, as higher income and education levels were consistently associated with greater awareness and higher vaccination rates. This observation aligns with international evidence highlighting the critical influence of socioeconomic status on vaccine-related decision-making.13,14 The persistence of cost as the dominant barrier, even after educational intervention, underscores the substantial structural burden imposed by high vaccine prices, particularly for lower-income families.14
One of the most important public health implications of this study is the demonstrated effectiveness of a brief, structured educational intervention delivered by physicians. The more than threefold increase in willingness to vaccinate underscores the power of targeted, evidence-based communication in shaping parental decision-making. Nevertheless, the continued influence of the vaccine’s exclusion from the national immunization program on perceptions of safety highlights the limitations of education alone. Prior studies have shown that inclusion in routine immunization schedules enhances public trust and vaccine confidence, emphasizing the relevance of this finding for national policy considerations.15 Despite targeted counseling, concerns regarding potential side effects remained prominent, consistent with reports from France, Italy, and the United States.16–18
This study has several limitations. Its single-center design and convenience sampling limit the generalizability of the findings. In addition, the physician-administered survey may have introduced social desirability bias, potentially inflating post-intervention willingness to vaccinate. The cross-sectional design also precludes causal inference. Nevertheless, the findings provide robust evidence that low baseline awareness and structural barriers – particularly cost and non-inclusion in the national immunization program – are major contributors to meningococcal vaccine hesitancy in Türkiye. In conclusion, strengthening physician-led communication and addressing financial barriers through policy measures, such as partial subsidies or inclusion of the meningococcal vaccine in the national immunization program, may substantially improve vaccine uptake.
Limitations of the study
This study has several important limitations that should be carefully considered when interpreting the findings. First, the study was conducted at a single center using a convenience sampling method, which severely limits the generalizability of the results. The study sample may not be representative of parents from different regions or healthcare settings, and therefore the findings cannot be readily extrapolated to the broader population. Despite this limitation, the study provides one of the first comprehensive assessments of parental perspectives on meningococcal disease and vaccination in Türkiye.
Second, data collection coincided with the COVID-19 pandemic, a period characterized by substantial changes in healthcare utilization and public perceptions regarding vaccines. Pandemic-related factors – such as altered healthcare-seeking behavior, increased parental sensitivity to vaccination issues, and disruptions in routine care – may have influenced parental responses and thus affected the study findings.
Third, although the questionnaire was pilot-tested on 20 parents to assess clarity, comprehensibility, and flow, this process was limited to face validity only and did not constitute a full psychometric validation. The instrument was not formally evaluated for content validity, construct validity, or internal consistency. Consequently, some degree of measurement error cannot be excluded, and the accuracy of the knowledge and attitude items may be limited.
Fourth, the questionnaires were administered face-to-face by a physician, which may have introduced social desirability bias. Parents may have over-reported positive knowledge levels, attitudes, or vaccination intentions in the presence of a healthcare professional. This bias may have artificially inflated the observed post-intervention willingness to vaccinate, particularly following the educational session.
Finally, multivariable analyses were not performed due to the limited sample size and sparse data in several categorical subgroups, which would have compromised model stability and interpretability. As a result, potential confounding variables could not be fully adjusted for, and the reported associations should be interpreted with caution. Future multicenter studies with larger and more diverse populations are warranted to allow robust multivariable modeling and to enhance the external validity of the findings.
Conclusion and recommendations
Our findings indicate that parental awareness and knowledge regarding meningococcal disease and its vaccines remain markedly low in Türkiye, and that these gaps are closely associated with limited vaccine uptake. Notably, even a brief, structured educational intervention was associated with a substantial increase in willingness to vaccinate, from 9.5% to a potential 31%, highlighting the possible effectiveness of targeted, evidence-based communication in influencing parental decision-making. In this context, recommendations from pediatricians and family physicians appear to play a particularly important role in shaping vaccine acceptance.
In light of these findings, strengthening provider – parent communication may represent an effective and feasible strategy to improve parental awareness and informed decision-making regarding meningococcal vaccination. Public health authorities may also consider implementing broader educational initiatives through widely used media and digital platforms, particularly to address persistent concerns related to vaccine safety. Furthermore, as vaccine cost emerged as the dominant barrier and the absence of the meningococcal vaccine from the national immunization schedule appeared to influence parental perceptions, policy approaches aimed at reducing financial barriers – such as partial subsidies or inclusion in the national immunization program – could potentially facilitate higher vaccination acceptance. Future multicenter studies and targeted interventions will be important to further evaluate these strategies and to inform evidence-based policies for improving meningococcal disease prevention in Türkiye.
Supplementary Material
Acknowledgments
This manuscript is derived from the medical specialty thesis of Dr. Şerif Şerifoğlu conducted at Haydarpasa Numune Training and Research Hospital. We would like to thank all participating parents for generously giving their time to complete the survey.
Şerif Şerifoğlu: methodology, project administration, data curation, statistical analysis, visualization, manuscript writing.
Tamay Gürbüz: review and editing.
All authors have read and approved the final version of the manuscript.
Biography
Şerif Şerifoğlu is a pediatric cardiology fellow at Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital in Istanbul, Turkey. He completed his residency in pediatrics at Haydarpaşa Numune Training and Research Hospital and is currently pursuing subspecialty training in pediatric cardiology.
Funding Statement
The author(s) reported there is no funding associated with the work featured in this article.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Consent to participate
Consent to participate was obtained from all subjects involved in the study.
Data availability statement
All data generated or analyzed during this study are included in this published article. No additional datasets were generated or analyzed.
Ethics approval
The study was initiated with the approval of the Clinical Research Ethics Committee of the University of Health Sciences, Haydarpaşa Numune Training and Research Hospital, dated 09.03.2020, with decision number HNEAH-KAEK 2020/33, and was conducted in accordance with the Declaration of Helsinki.
Informed consent statement
Informed consent was obtained from all subjects involved in the study.
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2616927
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data generated or analyzed during this study are included in this published article. No additional datasets were generated or analyzed.