Evaluating parents’ perceptions of infectious diseases and their levels of protection in terms of vaccination attitudes and vaccine hesitancy

Abstract

Background

This research was conducted to evaluate parents’ perceptions of infectious diseases and their levels of protection in terms of vaccination attitudes and vaccine hesitancy.

Methods

The research is descriptive and relational was conducted online with 560 parents of children aged 0–5 years between March 8 and November 8, 2024. Convenience sampling method was used in the study. For data collection, a questionnaire form including personal information form, Perception Scale on Communicable Diseases (PSCD), Parental Attitudes Towards Childhood Vaccines Scale (PACVS), and Vaccine Hesitancy Scale (VHS) in parents of children under five years of age was used. The evaluation of data was performed via SPSS V-27.0 package program.

Results

A total of 560 parents took part in this study, and the participants scored an average of 148.81 ± 18.53 points on the PSCD total, 53.42 ± 8.91 points on the Vaccine Attitude Scale total, and 24.89 ± 8.49 points on the Vaccine Hesitancy Scale total. PSCD explains 13.4% of the total PACVS score. A low-level statistically significant correlation was found between the total PSCD and VHS scores.

Conclusion

Parents’ communicative disease perception and their protection levels affect their vaccination attitudes and vaccine hesitancy. Sociodemographic characteristics, vaccine knowledge and the sources from which they obtain information have both positive and negative relationships on vaccine attitude and vaccine hesitancy. In order to prevent the increasing vaccine refusal in the society, it is recommended that health professionals inform parents through individualized trainings on immunization.

Background

Communicative diseases remain to be one of the leading causes of morbidity and mortality globally. It is estimated that this rate is even higher in low- and middle-income countries. In all age groups, infectious diseases, including diarrhoea and respiratory illnesses, are among the top ten causes of disease burden and mortality [1].

From past to present, it is seen that numerous epidemics such as typhoid, cholera, tuberculosis, malaria, smallpox, yellow fever, influenza, HIV/AIDS, and COVID-19 have occurred [2]. Vaccines have been of critical importance in preventing these diseases that have appeared over the last two centuries. The fundamental difference between vaccines and medications is that vaccines are administered as a preventive measure to healthy individuals, not to sick individuals [3]. In this context, vaccines are considered as milestones in the history of public health and medicine [4].

Prophylactic vaccines have been successfully used to combat infectious diseases in modern healthcare, and they are still used today. Viral diseases such as polio and smallpox, which caused the death of many children in the past, have been nearly eradicated because of vaccination, saving millions of children’s lives and preventing disabilities caused by these diseases [5]. In the countries which have high vaccination rates, the prevalence of infectious diseases such as diphtheria, tetanus, pertussis, mumps, measles, rotavirus, hepatitis B, pneumococcus, and rubella has significantly decreased [1, 6].

The risk of infectious diseases remains persistent today. The recent COVID-19 pandemic, which began in China, didn’t take long to spread worldwide. Increased convenience of transportation allows people to travel more frequently. Additionally, the rise in international wars and irregular migration has quickened the spread of infectious diseases [7].

While the development of vaccines during COVID-19 pandemic contributed to overcoming the pandemic, it is known that vaccine hesitancy increased among the people, including healthcare professionals, regarding the efficacy and side effects of vaccines. It is also noted that misinformation, misleading claims, and biased narratives about vaccines have spread widely in society, negatively effecting trust in vaccines [4, 8].

Appalling and sceptical narratives about vaccines, along with controversial conspiracy theories excessively circulating on social platforms, have undermined public trust in vaccines and vaccine providers, leading to vaccine hesitancy [9–11]. The most frequently reported concerns of parents were ranged as allergic reactions, autism, lack of information, chronic illnesses, and distrust in the pharmaceutical industry. Some parents also expressed that acquiring immunity naturally was healthier than vaccination [12–14]. Vaccine hesitancy that parents experience negatively impacts their attitudes toward vaccination. In the study by Akgül & Ergün (2023), it was determined that parents had vaccine hesitancy and expressed negative attitudes toward vaccines [12]. Altuntaş & Şahin (2022) found that a total of 75% of healthcare professionals encountered parents with vaccine hesitancy [15]. In the study by [16], it was seen that parents without vaccine hesitancy demonstrated positive attitudes toward vaccination [16].

On review of the literature, it is affirmed that parents often believe experiencing infectious diseases is healthier than vaccination, and that their hesitancy about vaccines is high, and accordingly vaccine attitudes are impacted negatively. At the same time, the increasing debate in Turkey in recent years regarding vaccine hesitancy is considered a significant public health issue in terms of the sustainability of childhood immunization services. Determining parents’ attitudes towards vaccination is important for developing strategies to prevent vaccine refusal and delays. Therefore, this study was designed with the aim of addressing the necessity of investigating the relationship of parents’ perceptions of infectious diseases and their level of protection on vaccine hesitancy and attitudes.

Research questions

1. What are the perception levels of parents about communicative diseases?

2. What are the attitudes of parents toward vaccines?

3. What are the levels of vaccine hesitancy among parents?

4. Is there a relationship between parents’ perception of communicative diseases, their attitudes toward vaccines and vaccine hesitancy?

Material and method

The aim, design and setting of the study

It is a descriptive and relational study. This research was conducted to evaluate parents’ perceptions of infectious diseases and their levels of protection in terms of vaccination attitudes and vaccine hesitancy. The study was carried out between March 8, 2024 and November 8, 2024. The study was conducted with parents who have children between the age of 0–5 years living in any province in Türkiye. Clinical trial number: not applicable.

Population and sample of the study

The study population consists of 11,406,406 parents with children aged 0–5 years registered in the Address-Based Population Registration System of the Turkish Statistical Institute (TÜİK, 2022) in 2022 [17]. Therefore, when determining the size of the proportions, the population was calculated as 384 people with a 95% confidence level and ± 5% control error using the known Turkish-language platform (medhesap.com) for sample size calculation [18]. To improve the representativeness and statistical reliability of the findings, data collection continued beyond the minimum sample size, and the study was completed with 560 parents.Convenience sampling method was used in the study. This sampling method is frequently used because it allows researchers to collect data from the population efficiently and cost-effectively [19].

Data collection method

The data for this study were primarily collected online via social media platforms from parents who met the inclusion criteria, either individually or through parent groups. When the target sample size could not be reached through online recruitment alone, additional data were collected face-to-face through interviews conducted by the researchers. Accordingly, 26 parents participated through face-to-face interviews.During the face-to-face data collection process, participants were informed about the aim and procedures of the study, the voluntary nature of participation, their right to withdraw from the study at any time without any consequences, and the confidentiality of their responses. No personally identifiable information was collected, and anonymity was maintained throughout the study. Informed consent was obtained from all participants prior to data collection.

Inclusion Criteria: Having a child between the ages of 0–5, being able to read and understand Turkish, being open to communication and cooperation, having no sensory loss like visual or hearing impairments, and volunteering to participate in the study.

Exclusion Criteria: Parents who demanded to withdraw from the study at any stage, those who filled out the questionnaire form incompletely or incorrectly, and who did not live with their child were not included to the study.

Data collection tools

The data of this study were collected with a questionnaire including personal information form, PSCD, PACVS, and VHS in Parents of Children Under Five.

Personal information form

This form is an information form prepared by the researchers based on the literature and it consists of 10 questions. It comprises information about age, gender, education level, employment status, income level, number of children, knowledge about vaccines, sources of vaccine-related information, vaccination during infancy, and paid vaccination status [13, 20, 21].

PSCD

This scale was developed by Gökmen-Demir et al. (2022) to measure perceptions regarding infectious diseases [22]. It involves of 34 items divided into two subdimensions. Responses are scored on a 1–5 likert type scale, graded from “strongly agree” to “strongly disagree.” The total score ranges from a minimum of 34 points to a maximum of 170 points. The General Perception and Perception of Prevention Ways sub-dimension consists of items between 1 and 26. The lowest score that can be obtained from this subscale is 26 and the highest score is 130. The Perception of Transmission Sub-dimension consists of items between 27 and 34. The lowest score that can be obtained from this subscale is 8 and the highest score is 40. The total Cronbach’s alpha value of the PSCD was found to be 0.98 [22].

PACV

The scale was developed by Opel in 2011 and includes 15 items and three sub-dimensions (general attitudes, safety-effectiveness and behaviour) [20]. The Turkish validity and reliability were performed by Çevik et al. (2020) and Mutlu (2021) and the Cronbach alpha value was determined to be 0.845 [23, 24]. In this study, the Cronbach alpha value of the PACV Scale was found to be 0.842, while the sub-dimension Cronbach alpha values ranged between 0.824 and 0.867, respectively. Though the scoring of the scale is carried out in different ways, the raw score that can be obtained from the scale is a value between 0 and 30. These scores are then re-evaluated according to the score conversion table provided in the scale developed by Opel et al. (2011) and transformed into values between 0 and 100. If the total transformed score of the parent participating is less than 50 in the scale, it is defined as a parent without vaccine hesitancy; if the score is 50 points or higher, it is defined as a vaccine hesitant parent [20].

VHS in parents of children under five

It was established by Larson et al. to measure the attitudes of parents with children aged between 0 and 5 years about vaccination [25]. Its Turkish validity and reliability were performed by Soysal et al. [26]. The VHS is comprised of a single factor and 7 items to determine vaccine hesitancy in parents with children under five years of age. The scale is a 5-point Likert scale ranging from (1) strongly disagree and (5) strongly agree. Cronbach’s α value was calculated as 0.83.Cronbach’s alpha values of the measurement tools used in this study are presented in Table 2.

Table 2.

Distribution of participants’ total scores on the PSCD, PACV subdimensions, and VHS for parents of children under five (N = 560)

	No.of items	Min.-Max.	Mean ± SD	Cronbach alfa
PSCD total	34	35.00–170.00	148.81 ± 18.53	0.968
The General Perception and Perception of Prevention Ways sub-dimension	26	27.00–130.00	115,69 ± 13.95	0.965
The Perception of Transmission Sub-dimension	7	8.00–40.00	33.11 ± 5.92	0.906
PACV	15	31.00–75.00	53.42 ± 8.91	0.678
PACV General Attitudes Sub-dimension	6	8.00–40.00	29.41 ± 6.97	0.797
PACV safety-effectiveness sub-dimension	4	4.00–20.00	10.53 ± 4.49	0.902
PACV behavior sub-dimension	5	5.00–21.00	13.47 ± 2.89	0.604
VHS	7	7.00–35.00	24.89 ± 8.49	0.966

Evaluation of the data

SPSS V-27.0 package program was used to evaluate the data. Descriptive statistical methods (frequency, percentage, mean, standard deviation) were employed in the evaluation of the data. The normality assumption of the data was estimated based on the skewnes kurtosis ± 2 value [27]. Since the parametric test assumption was met for the analysis, independent samples t-test, One-Way ANOVA and LSD and Bonferroni test were applied for post hoc test. For the relationship between the measurement tools, simple linear regression analysis was carried out to determine the regression and effect size. Pearson correlation analysis is a method which is used to determine the direction and strength of relationships between variables [28]. Pearson correlation coefficients (r) were explained as follows: no correlation (r = 0.00), low level (r = 0.01–0.29), moderate level (r = 0.30–0.70), high level (r = 0.71–0.99) and perfect correlation (r = 1.00). Statistical significance was determined at a threshold of p < 0.05 [28, 29].

Results

This study was accomplished with the participation of 560 parents. The mean age of the parents was 32.85 ± 7.07 and the average number of children was 2.12 ± 1.23. A total of 74.6% of the participants were female, 41.8% were university graduates, 55.7% were employed, 50.9% had an income above the minimum wage, 91.6% had knowledge about vaccines, 38.6% obtained information about vaccines from doctors and 94.3% had their children vaccinated. Excluding the free routine vaccines included in the national childhood immunization schedule, 32.5% of parents reported having their children vaccinated at a cost (Table 1).

Table 1.

Distribution of socio-demographic characteristics of participants

		Min-Max	Mean ± SD
Age		18.00–65.00	32.85 ± 7.07
Number of Children		01.00–07.00	2.12 ± 1.23

		N	%
Gender	Female	418	74.6
	Male	142	25.4
Education Level	Primary school	123	22.0
	High School	203	36.3
	University	234	41.8
Employment Status	Employed	312	55.7
	Unemployed	248	44.3
Income Level	Below the minimum wage	97	17.3
	Minimum wage	178	31.8
	Above the minimum wage	285	50.9
Informed about the vaccines	Yes	513	91.6
	No	47	8.4
Source of Information ab. vaccines	No information	47	8.4
	Doctor	216	38.6
	Nurse/Midwife	199	35.5
	Friend/Social environment	42	7.5
	Newspaper/Magazine	3	0.5
	Television	6	1.1
	Internet	47	8.4
Having their children vaccinated	Yes	528	94.3
	No	32	5.7
Paid-vaccination	Yes	182	32.5
	No	378	67.5

Table 2 shows the distribution of participants’ total scores of PSCD sub-dimensions, vaccine attitude scales and vaccine hesitancy scales. Participants got 148.81 ± 18.53 points from PSCD total score, 53.42 ± 8.91 points from vaccine attitude scale and 24.89 ± 8.49 points from vaccine hesitancy scale.

The distribution of vaccine hesitancy among participants, based on their Vaccine Attitude Scale scores, is shown in Fig. 1. A total of 66.43% of the participants exhibited vaccine hesitancy (Fig. 1).

Fig. 1.

The hesitancy condition of participants according to the VHS

It was found out to be statistically significant results between the participants’ education level, employment status, income level, knowledge about vaccines, source of information about vaccines, vaccination status of their children, paid vaccination status and the total score of the PSCD (p < 0.05). Those who were university graduates scored higher than those who had a primary school degree, the scores of the ones who were employed were higher than those who were not employed, those whose income levels were above minimum wage had higher scores than those whose income levels were minimum wage and below minimum wage, those who had information about vaccines scored higher than those who did not have information about vaccines, those who received information about vaccines from doctors, nurses, friends/social environment and the internet had higher scores than those who did not receive any information, those who had their children vaccinated had higher scores than those who did not, and those who had paid vaccination had higher scores than those who did not (p < 0.05). There were no statistically significant results between the gender of the participants regarding the total score of the PSCD (Table 3; p > 0.05).

Table 3.

Comparison of participants’ socio-demographic characteristics with PSCD, PACV Scale, and VHS total scores

Socio-Demographic Characteristics		PSCD Total	Test/Significant	PACV Scale	Test/Significant	VHS Scale	Test/Significant
		Mean ± SD		Mean ± SD		Mean ± SD
Gender	Female	148.65 ± 18.63	t=−0.345 p=0.730	53.14 ± 8.77	t=−1.298 p=0.195	25.15 ± 8.26	t = 1.265 p=0.206
	Male	149.27 ± 18.29		54.26 ± 9.32		24.11 ± 9.09
Level of Education	Primary sch.a	144.81 ± 20.95	F = 5.470 p=0.004* a < c	53.09 ± 8.58	F = 1.803 p=0.166	23.11 ± 8.51	F = 3.678 p=0.026* a < b,c
	High Sch.b	148.17 ± 17.18		52.67 ± 9.13		25.66 ± 7.76
	Universityc	151.46 ± 17.94		54.25 ± 8.86		25.15 ± 8.97
Employment Status	Employed	151.08 ± 18.27	t = 3.283 p = 0.001	54.80 ± 8.87	t = 4.144 p < 0.001	25.19 ± 8.76	t=0.962 p=0.337
	Unemployed	145.95 ± 18.48		51.70 ± 8.68		24.50 ± 8.13
Income Level	Lower than minimuma	143.88 ± 19.04	F = 7,340 p =0.001** a, b < c	51.22 ± 8.37	F = 6,254 p =0.002* a, b < c	25.09 ± 7.78	F=0.070 p=0.933
	Minimumb	147.15 ± 16.54		52.70 ± 8.58		24.71 ± 8.25
	Higher than minimumc	151.51 ± 19.11		54.63 ± 9.13		24.93 ± 8.88
Informed ab.vaccines	Yes	149.60 ± 17.68	t = 3.396 p = 0.001	53.87 ± 8.88	t = 3.967 p < 0.001	24.96 ± 8.67	t=0.662 p=0.508
	No	140.10 ± 24.62		48.55 ± 7.82		24.10 ± 6.12
Source of Information	No informationa	140.10 ± 24.62	F = 2.751 p=0.012* a < b,c, d,g	48.55 ± 7.82	F = 4.843 p< 0.001* a < b,c, d,g	24.10 ± 6.12	F=0.409 P=0.873
	Doctorb	148.12 ± 19.38		52.62 ± 8.64		25.03 ± 8.48
	Nursec	151.35 ± 16.17		55.29 ± 8.86		25.25 ± 8.96
	Friends/Social environ.d	147.88 ± 17.74		53.73 ± 10.02		24.80 ± 7.99
	Newspaper/Magazinee	160.00 ± 8.54		49.66 ± 12.85		20.00 ± 9.84
	Televisionf	145.33 ± 13.86		48.50 ± 9.39		23.16 ± 8.20
	Internetg	150.44 ± 16.00		54.72 ± 7.97		24.10 ± 9.15
Status of having children vaccinated	Yes	149.19 ± 18.19	t = 1.999 p = 0.046	53.75 ± 8.90	t = 3.562 p < 0.001	25.11 ± 8.48	t = 2.532 p = 0.012
	No	142.46 ± 22.74		48.03 ± 7.47		21.21 ± 7.90
Paid-vaccination	Yes	151.54 ± 17.23	t = 2.437 p = 0.015	54.19 ± 8.03	t = 1.417 p = 0.157	25.44 ± 8.65	t = 1.072 p = 0.284
	No	147.49 ± 19.00		53.05 ± 9.30		24.62 ± 8.40

t t test in independent groups, f One-Way ANOVA

In this table, different letters (a, b, c, …) are used to represent different groups within each variable (e.g., educational level, Income Level, Source of Information)

*LSD test were performed

**Bonferroni test was performed

The numbers highlighted in bold in the table are used to emphasize statistical significance

There were statistically significant results between the participants’ employment status, income levels, information about vaccines, source of information about vaccines, vaccination status of their children and the total score of the PACV Scale (p < 0.05). The total score of the PACV Scale was also significantly higher among the participants who were employed compared to those who were not employed, those whose income levels were above minimum scored higher than those whose income levels were minimum and below minimum wage, those who had information about vaccines had higher scores than those who did not, those who received information about vaccines from doctors, nurses, friends/social environment and the internet scored higher than those who did not, and the scores of those who had their children vaccinated were higher than those who did not (p < 0.05). There were no statistically significant results between participants’ gender, education level, or paid vaccination status regarding the total PACV Scale scores (Table 3; p > 0.05).

However, statistically significant results were found between the participants’ education level, vaccination status of their children, regarding the total scores of the VHS (p < 0.05). Participants with high school or university education scored higher on the VHS than those with primary school education and participants who had their children vaccinated scored higher than those who did not (p < 0.05). There was no statistically significant results between participants’ gender, employment status, income level, knowledge about vaccines, sources of vaccine-related information, or paid vaccination status regarding the total VHS scores (Table 3; p > 0.05).

A moderate positive correlation was found between participants’ age and their total PSCD scores and the “General Perception and Perception of Prevention Ways” subscale scores. A weak positive correlation was observed between age and the PACV and the “General Attitude” and “Safety-Effectiveness” subscales, while a weak negative correlation was found between age and the PACV “Behaviour” subscale and VHS (p < 0.05). Furthermore, a weak positive correlation was detected between the total PSCD scores and both vaccine hesitancy and vaccine attitudes total and subdimentions (the PACV general attitude and safety- effectiveness), while, PACV behavior revealed weak negative correlation (p < 0.05; Table 4).

Table 4.

Relationship between participants’ age, PSCD total and subdimensions, PACV scale total and subdimensions, and VHS

		(1)	(2)	(2 A)	(2B)	(3)	(3 A)	(3B)	(3 C)	(4)
Age (1)	r	1	0.089*	0.087*	0.074	0.161**	0.144**	0.160**	− 0.100*	− 0.102*
	p		0.034	0.039	0.081	0.000	0.001	0.000	0.018	0.016
PSCD Total (2)	r	0.089*	1	0.972**	0.836**	0.365**	0.394**	0.192**	− 0.123**	0.131**
	p	0.034		0.000	0.000	0.000	0.000	0.000	0.003	0.002
PSCD General Perception and Perception of Prevention Ways (2 A)	r	0.087*	0.972**	1	0.685**	0.361**	0.398**	0.178**	− 0.123**	0.131**
	p	0.039	0.000		0.000	0.000	0.000	0.000	0.003	0.002
PSCD Perception of Transmission (2B)	r	0.074	0.836**	0.685**	1	0.292**	0.296**	0.181**	− 0.095*	0.102*
	p	0.081	0.000	0.000		0.000	0.000	0.000	0.024	0.016
PACV Total (3)	r	0.161**	0.365**	0.361**	0.292**	1	0.905**	0.732**	− 0.237**	0.196**
	p	0.000	0.000	0.000	0.000		0.000	0.000	0.000	0.000
PACV General Attitude (3 A)	r	0.144**	0.394**	0.398**	0.296**	0.905**	1	0.499**	− 0.395**	0.187**
	p	0.001	0.000	0.000	0.000	0.000		0.000	0.000	0.000
PACV Safety-Effectiveness (3B)	r	0.160**	0.192**	0.178**	0.181**	0.732**	0.499**	1	− 0.501**	0.087*
	p	0.000	0.000	0.000	0.000	0.000	0.000		0.000	0.040
PACV Behaviour (3 C)	r	− 0.100*	− 0.123**	− 0.123**	− 0.095*	− 0.237**	− 0.395**	− 0.501**	1	0.020
	p	0.018	0.003	0.003	0.024	0.000	0.000	0.000		0.639
VHS Total (4)	r	− 0.102*	0.131**	0.131**	0.102*	0.196**	0.187**	0.087*	0.020	1
	p	0.016	0.002	0.002	0.016	0.000	0.000	0.040	0.639

*Correlation is significant at the 0.05 level (2-tailed)

**Correlation is significant at the 0.01 level (2-tailed)

 The numbers highlighted in bold in the table are used to emphasize statistical significance

A simple linear regression model was used to evaluate the relationshipof the PSCD total score on the PACV scale total score. Statistical estimates of the model supported that the model was significant and adaptable (Table, 5; p<0.001). It was seen that the total of the PSCD explained 13.4% of the total of the PACV scale [F(1, 558) = 85.983, R2=0.134].

Table 5.

The relationship of PSCD total score on PACV total score and VHS total score

							95.0% Confidence Interval for B
		B	SE	Beta	t	p	Lower Bound	Upper Bound
Dependent Variable: PACV	(Constant)	27.257	2.844		9.584	< 0.001	21.671	32.844
	PSCD Total	0.176	0.019	0.365	9.273	< 0.001	0.139	0.213
F(1, 558) = 85.983, R=0.365, R2=0.134, Adjusted R2=−0.132, Durbin Watson = 1.581, p<0.001

							95.0% Confidence Interval for B
		B	SE	Beta	t	p	Lower Bound	Upper Bound
Dependent Variable: VHS	(Constant)	15.952	2.883		5.532	< 0.001	10.288	21.615
	PSCD Total	0.060	0.019	0.131	3.124	0.002	0.022	0.098

F(1, 558) = 9.760, R=0.131, R²=0.017, Adjusted R²=0.015, Durbin Watson = 1.649, p=0.002

The numbers highlighted in bold in the table are used to emphasize statistical significance

To find out the relationship of the total PSCD score on the total VHS score, a simple linear regression model was employed and the statistical estimates of the model affirmed that the model was significant and adaptable (Table, 5; p<0.001). It was observed that the PSCD total explained 1.7% of the VHS Total [F(1, 558) = 9.760, R2=0.017].

Discussion

This study was administered to investigate the relationship of parents’ perception of infectious diseases and prevention levels on vaccination attitude and vaccine hesitancy across Türkiye.

Individuals’ perceptions about diseases are important in establishing their health behaviours. Health behaviours have either positive or negative impacts in terms of the spread of infectious diseases [22]. In this study, the sub-dimensions and total scores of the PSCD, which was used to measure parents’ perception of diseases, were found to be high. In the study by Güdücü and colleagues (2023), nursing students were found to have high PSCD scores, a finding that is consistent with the results of this study [30]. In this regard, the fact that the PSCD scale scores were similar across different sample groups suggests that this enhances the reliability of the findings. In the study by Güdücü et al. (2023), nursing students and in the study by Sarı (2025), adults living in rural areas were found to have high PSCD scores [30, 31]. In this context, it is observed that studies, especially those with the same population, are limited in the literature. Therefore, it is thought that although PSCD scale scores show similarities in different sample groups, the comparison should be carefully evaluated due to sample differences.

In this study, the total scores of PSCD were found to be higher in university graduates, employees, those with an income level above the minimum wage, those who were informed about vaccines, those who received information from healthcare professionals and the internet, those who had their children vaccinated, and those who had paid-vaccinations. As the level of education increases, individuals become more sensitive to topics such as health, diseases, actions taken to protect health, and preventive measures [32]. Alankaya & Kurnaz (2022) expressed in their study that university graduates had higher levels of awareness and consciousness about vaccines and diseases and their perception of disease were stronger [2]. It was noted that individuals were more likely to take preventive measures against infectious diseases when their education levels were higher [33].

Taking the findings of the study into account, it could be concluded that the perceptions of infectious diseases were higher among employed parents and the parents who had an income above the minimum wage. Being employed and having a certain socio-economic status positively affect health literacy and thus individuals’ disease perceptions just as the education level does [34]. It is regarded that individuals with higher income levels have easier access to health services and have better perceptions of infectious diseases, which is thought to positively affect the status of having their children vaccinated.

Today, social media is a means where a vast amount of information, either accurate or inaccurate, about diseases can easily be found [35]. It is critically important to distinguish accurate, unbiased information from insignificant and misleading information on the internet. In a study, it was stated that individuals who learned information about vaccines from the internet were more likely to have negative information about preventive measures [36]. On the contrary, parents who were informed by health professionals such as doctors and nurses and who were able to ask openly in face-to-face conversations about what they were curious about were found to have increased disease awareness due to Access to accurate information [37–39], noted in their study that disease-related information obtained from social media and friends negatively affects individuals’ perception of infectious diseases and prevention methods [39]. In this study, it is considered that getting information about diseases mostly from healthcare professionals and from the internet positively associated with the perception of diseases.

It was observed that the majority of the parents participating in the study were female and had knowledge about childhood vaccines and had their children vaccinated. It was seen that most of the parents participating in the studies were female and possessed sufficient knowledge about vaccines [12, 16]. The majority of the participants in the study by [16] reported that their children were vaccinated on time, and they expressed the necessity of vaccines [16]. It is considered that mothers’ feeling themselves primarily responsible for vaccines encourages them to possess information about vaccines and to have their children vaccinated.

Childhood vaccinations save an approximate 2–3 million lives worldwide each year and are among the first measures to be taken to reduce mortality and morbidity caused by preventable diseases [40]. Parents who are more aware of the disease are more likely to protect their children’s health and believe that vaccines are necessary, which is linked to higher vaccination rates [36, 39]. However, access to paid vaccines still remain impossible for many families. Among the reasons for paid-vaccines being unattainable, the leading ones are lack of knowledge about vaccines and high cost for parents with multiple children [41, 42]. In this study, parents who got paid vaccinations in addition to routine vaccinations had higher PSCD scores compared to those who did not. Families with higher income levels prefer paid vaccines more than those with lower income levels [34]. It was thought that the income status of parents with high disease perception was not considered as an obstacle for access to paid vaccines. It was stated that the perception of communicable diseases was not related to gender factor. [43] reported that the perception of infectious diseases does not change according to gender; in Kurtdaş’s (2024) study, it was emphasized that women are more susceptible to infectious diseases compared to men [44].

The World Health Organization (WHO) has asserted that parents’ attitudes towards vaccination are crucial in achieving the vaccination target rate [45]. Among the most common reasons for vaccine hesitation are fear of side effects and perceived lack of information, and these reasons have negative effect on individuals’ positive attitude towards vaccination and vaccine acceptance [39]. It is essential to determine parents’ attitudes towards vaccines for preventing vaccine hesitation and refusal and for planning the necessary interventions. According to the research findings, the total score of the PACV Scale, which measures parents’ attitudes towards vaccines, exhibit the parents’ vaccine hesitancy. Similarly, Turan (2022) reported that parents had vaccine hesitancy. Vaccine hesitancy is an increasingly complex and multifaceted phenomenon [21]. Many different reasons are associated with parents’ decision-making process, such as personal experiences, information sources like social media, the internet and others [38].

According to the study’s findings, gender and education level were not associated with parents’ attitudes toward vaccination. Whereas some studies have stated that women have lower vaccine attitudes compared to men [46], some studies in which gender and education level were not associated vaccine attitudes were also present, which is similar to our findings [12, 21]. It was considered that vaccination attitude might be affected by other environmental or individual factors.

In this study, the PACV scale score of parents who were employed and whose income levels were above the minimum wage was found to be higher. In a study conducted in Türkiye, it was reported that there was a relationship between parents’ income levels and vaccination attitudes towards their children [47]. In a study by Üzüm et al., (2019), it was found that low-income level negatively affected childhood vaccination rates [48]. The culture of the society and some socio-demographic characteristics of the community affect the vaccination of children This study hypothesizes that attitudes towards vaccination may be related to individual and environmental factors, in addition to employment status and income level.

In this study, it was determined that parents who had got information about vaccines and even those who received that information from the internet were vaccine hesitant parents according to the PACV scale. It is determined that anti-vaccine rhetorics on social media platforms boost vaccine hesitancy and cause mistrust towards newly developed vaccines [49]. Literature shows that scientifically unproven misinformation negatively impacts vaccine attitudes [21, 39, 49]. Therefore, it is stated that people who receive information online experience vaccine hesitancy compared to those who do not.

In this study, it was found out that the vaccination attitude scale scores and vaccine hesitancy were higher in parents who received vaccines compared to those who did not. In a study, parents who had their children vaccinated expressed their concerns about the possible side effects of vaccines. Even symptoms such as fever and pain experienced after vaccine administration cause parents to experience anxiety [47]. In the study by Çevik et al., (2020), it was determined that more than half of those who had hesitations about vaccines hesitated due to the side effects of the vaccine [23]. Accordingly, the fact that parents decide to vaccinate their children despite experiencing hesitation is related to a wide variety of factors, including protecting the child’s health, the recommendations of healthcare professionals, and institutional health policies. It also suggests that the vaccination decision-making process is multifaceted and complex. It is an expected result that parents do not want to administer paid-vaccines and newly developed vaccines in addition to routine vaccines while experiencing vaccine hesitation. Similarly, İnce et al., (2024) reported in their study that parents did not want to have paid-vaccines even though they have information about them [42]. Alongside the hesitancy toward paid-vaccines, the limited demand for vaccines may also be connected with the economic burden on the family [41, 42]. Moreover, in this study, vaccine hesitancy in the participants who were high school and university graduates was found to be higher than primary school graduates. In another study, it was found that trust in vaccines decreased as the education level of parents increased [36]. The result of that research has similarities with the result of this study. It is obvious that the higher education level the society have, the more extensive research the parents do about the vaccination for their children.

It was found out that there was a moderate level of positive correlation between the participants’ ages and their total PSCD scores and the scores of general perception and preventive measures. It was detected that total of PACV scale, and the VHS were explained in the total score of PSCD. In the studies of Yıldız et al., (2021) and Alshammari et al., (2021), it was reported that as the age of the participants increased, the perception of disease enhanced and negative thoughts about vaccines lessened [50, 51]. [43] stated that participants in the younger age group thought that vaccines were more dangerous, and they raised the risk of disease transmission [52]. Young people having inadequate knowledge about the diseases that could be prevented by vaccines and having misleading information about vaccines from friends and from their social environment also lead to a decrease in disease perception [53]. The studies on this subject reinforce the research. We assumed that as the parents get older, their awareness levels and perceptions about the disease increase. The fact that parents have incorrect information about vaccine-preventable diseases leads to vaccine hesitation and thus their vaccination attitudes are negatively affected. Parents should be provided with valid and proper information by means of trainings organized about vaccines and diseases.

A positive weak correlation was found between the sum of the PSCD and vaccination attitude and vaccine hesitancy in this study. It was observed that the total score of the PSCD explained 13.4% of the total of the PACV scale and 1.7% of the total of the VHS. In the meta-analysis study of Diaz et al., (2020), it was also expressed that parents who hesitated to have their children vaccinated did not have sufficient knowledge about vaccines and diseases [54]. It was noted that parents with vaccine hesitation did not participate in educational programs, underwent psychological problems or difficult periods, and had busy lives [55]. The results of our study are consistent with the results of those studies. Studies examining the PACV and VHS scales together are limited in the literature. The fact that both scales examine parental attitudes towards childhood vaccination across different dimensions allows for a more comprehensive understanding of their relationship regarding vaccination attitudes. Furthermore, using both scales in the same sample will contribute to filling the gap in the existing literature. Parents’ perceptions of the disease were found to be associated with vaccine hesitancy and attitude towards vaccination. The fact that parents lack accurate and adequate information about the diseases and vaccines generates vaccine hesitation. This situation also affects vaccine attitudes negatively. To conclude, anti-vaccine ideas spreading on social platforms and among friends are often as claims without any scientific basis; however, they influence the whole society and most importantly the parents who raise the future generations. Healthcare professionals should provide people with information by establishing non-confrontational and explanatory solid foundations based on trust and strong relationships. A personalized approach is considered to be effective in dealing with vaccination attitudes and hesitation.

Conclusion

This study was carried out to determine the relationship of parents’ perceptions of communicable diseases and their protection levels on vaccination attitude and vaccine hesitancy. The findings suggested that although parents had high perceptions of infectious diseases, they also experienced vaccine hesitancy. In addition, parents’ perceptions of communicable diseases appeared to play a role in shaping their vaccination attitudes and vaccine hesitancy. The results of the study indicated that education level, employment status, income level, and knowledge about vaccines were significantly associated with perceptions of infectious diseases. Moreover, a positive correlation was found between parents’ ages and their perceptions of infectious diseases, suggesting that as age increased, individuals’ perception and protection levels regarding communicable diseases also tended to increase. It was also observed that parents’ level of information and their sources of information about communicable diseases were significantly associated with their attitudes toward vaccination. Analysis of the total scores on the vaccine hesitancy scale showed that parents with high school and university degrees tended to have higher hesitancy scores than parents with primary school degrees. Similarly, parents who had their children vaccinated appeared to report higher vaccine hesitancy scores compared to those who did not vaccinate their children. Regression analysis further indicated that perceptions of communicable diseases explained 13.4% of the PACV total score and 1.7% of the VHS total score. These findings suggest that perceptions of communicable diseases may play an important role in shaping parents’ vaccination attitudes and hesitancy.

Difficulties and limitations of the Study

Since online surveys were conducted to parents in the study, individuals with the incapability of online survey application might have had low survey participation rates, might have refused to be interviewed, and the answers to the questions may have varied in case of misunderstandings. Additionally, the study was limited to the inclusion of individuals who had internet access and the ability to use social media, which could be considered as a limitation of the study. Another limitation of the study is that, due to the use of convenience sampling and the lack of data on the geographical distribution of participants, representation from all regions could not be ensured.

Recommendations based on the findings

Informative seminars and individual counselling services should be offered to parents in order to reduce vaccine hesitancy. With a view to gain deeper understanding of the relationship between communicable disease perception, vaccination attitudes and vaccine hesitancy, further research using stratified sampling or international comparisons should be conducted. The findings of this study suggest that improving parents’ perceptions of infectious diseases and vaccines is of critical importance for public health. It is recommended that health policies should focus on increasing parents’ knowledge levels and promoting positive attitudes toward vaccination.

Authors’ contributions

Concept: G.G., H, İ., N.A., C.M.A., Ö.K., A.Ç. Design: G.G., H, İ., N.A., C.M.A., Ö.K., A.Ç. Data Collection or Processing: G.G., H, İ., N.A., C.M.A. Analysis or Interpretation: G.G., Literature Search: G.G., H, İ., N.A., C.M.A., Ö.K., A.Ç. Writing: G.G., H, İ., N.A., C.M.A.

Funding

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

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Declarations

The authors have not declared any potential conflicts of interest regarding researching, authoring, and/or publication of this paper.

Ethics approval and consent to participate

Approval of ethics committee was obtained from Kafkas University Non-Interventional Research Ethics Committee with the approval number 81829502.903/15 dated February 28, 2024. Permission was also obtained for the use of the measurement tools in the study. In addition, parents who met the inclusion criteria and agreed to participate in the study were informed about the study and provided their written and verbal consent. All participants were also made aware of their right to withdraw. The study was conducted in compliance with the rules in the Helsinki declarations and STROBE observational research guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.