Table 2.

Observations of the participants about the concerns of families with vaccine refusal

Topic	Statements
Necessity of Vaccines
	“Senior member of the family says that there was no vaccine in our youth. However, we have grown up as right as rain”.(Şanlıurfa) “Disease is more “natural” than a vaccine.” (Şanlıurfa and Diyarbakır) “Not all vaccines are necessary.” (Trabzon, Malatya provinces and Mediterranean region)
Vaccine Safety
Overload the immune system	“Parents say the number of simultaneous vaccinations is too high and unnecessary. Therefore, the vaccine calendar must be rearranged.”(Istanbul)
Vaccine additives	“It is said that vaccines include monkey blood, mercury, and pig blood.” (Istanbul, Bolu, Düzce, Gümüşhane, Kütahya).
May make the child sick (SSPE, autism, cancer) and any adverse reaction after the previous vaccination	“Increased SSPE incidence in the region causes definite vaccine rejection in the affected families and also in other families in that region. The fact that SSPE cases are not related to vaccination is not fully explained; in 1990–2000, increased cases were linked to the vaccine, the effects of which still continue.”(Diyarbakır) “there is a teacher, his child got SSPE …, and he scares other teachers and families with erroneous non-scientific information, as a result of which both childhood and infancy vaccination rates in that district are reduced.” “I have doubts about vaccination, too. In one family, there is a vaccinated child who has recently been diagnosed with leukemia; I have hesitations for that reason. My child is vaccinated, but I have doubts about how much of a protective effect it has.”(nurse, Diyarbakır)
Believing that vaccine changes genetic codes because of additives	“As vaccines come from abroad, families think their children would be retarded if vaccinated, and they believe the countries that produce vaccines do not vaccinate their own children who will take the country forward.” (Konya) “It is said that there is pork blood in the vaccine; it’s therefore haram, and the most important fact is that it makes our children infertile; they do not want to use any birth control either.” (Bingöl) “It is said that you will sterilize us with the vaccines.” (Diyarbakır)
HCWs’ vaccine hesitancy and misinformation
Negative information of HCWs regarding vaccination	“There’s a professor, a pediatrician, at the university. He says ‘do not vaccinate your child, a child should not be vaccinated for the first two years of his/her life.’ Moms trust him, not me.” (İstanbul) “In particular, negative attitudes of obstetricians to vaccines during pregnancy cause mothers to take a negative approach the vaccination of their babies.” (Ankara) “Obstetricians have an important role in vaccination refusal. Women safely commend themselves to doctors, and they believe that doctors will not misdirect them. Therefore, in the light of the negative information given by obstetricians, women are not vaccinated with tetanus diphtheria toxoids vaccine/tetanus diphtheria toxoids and acellular pertussis vaccine and even hesitate to vaccinate their children.”(Karabük) “Women report that their obstetricians say there is no need for vaccination and they perform all necessary initiatives during their follow-up visits.”(İstanbul)
Self-refusal, anti-vaccine approaches among HCWs	“The Ministry of Health sent an official document, saing that health workers born between 1980 and 1990 should be vaccinated. Of them, 90% refused, I could not vaccinate them. In the case of the measles outbreak, health workers had refused vaccination. In our field, we are aiming to achieve something in which he does not believe. The man is a health worker; however, he is not vaccinated, and then he tells families ‘go and vaccinate your children’. Above all, those who do this work have to believe in their job.”.(Bayburt)
Distrust of some families regarding the National Health System or its components
Mistrust of government health authorities	“In families who are members of some special religious orders, women avoid obstetric care, are not being given pregnancy vaccinations, and some of them evade healthcare and vaccines by giving birth at home. Some religious groups have their own television and radio channels, and members base their health behaviors on the information given in these channels.” (İstanbul) “A remarkable proportion of dedicated followers of some religious orders do not trust state hospitals, they prefer to use small private hospitals. These people are avoiding vaccination.” (Yalova) “Local people do not trust state hospitals due to their ethnicity, and for that reason they refuse vaccination.” (Diyarbakır)
Distrust of organized medicine and public health	“Some remarkable groups are not vaccinated, and do not even benefit from any health services. They prefer alternative medicine, giving birth at home with the help of district midwives or a labor coach. They hide their pregnancy, and they do not enter pregnancy follow-up programs of the family health unit, because of distrust.” (Konya) “Some families go to polyclinics belonging to their cults/groups instead of going to public health institutions; they do not trust state programs and are not vaccinated.” (Ankara)
Distrust of foreign pharmaceutical companies	“Families state that vaccines were developed by foreign states to make them infertile, so they refuse vaccines and … they do not trust them.” (Bingöl) “Refusal reasons indicated state that vaccines are foreign-originated, and there are unsuitable ingredients.” (Yalova, Konya) “They refuse vaccines because vaccines are deployed as a biological weapon, and they come from abroad, so they have content which causes genetic code change.” (Istanbul)
Insufficient control within the country	“A family said … … .bring us the vaccine label, show the approval and control of Republic of Turkey … …. let the vaccine label write the halal statement and commission approval; show me, then I will have my child vaccinated.” (Konya).
Ethical, moral or religious reasons
	“Parents say … .. there are some substances which are not suitable for religion, administering a foreign substance to the body from outside is not appropriate for religion, too.”(İstanbul, Bayburt, Konya) “Parents state … … ..vaccination is a sin, forbidden by religion.”(Bolu, Trabzon) “Families refusing vaccination mention … … .. the vaccine has been invented to disrupt the blood, and it is illicit.”(Gümüşhane, Ankara, Bingöl) “Cult leaders in the region do not permit their denominated families to vaccinate their children, and therefore give them anti-vaxxer information.”(Diyarbakır, Bingöl, Konya, Ankara, İstanbul)
Social Media Consulting
	“Anti-vaxxer groups share anti-vaccination conversations, stories, publications, broadcasts. Particularly, tweets sent by an eminent television actress cause quite negative effects.”(Karabük) “Especially media channels, bloggers, and brochures of anti-vaxxer groups cause insecurity regarding vaccine ingredients.”(Istanbul) “There is a book that includes anti-vaxxer articles and is sold online; it is spreading fast, and information in this book popularize anti-vaxxer views.”(İzmir) “They read and learn something on their own and ask questions …. I could not refute their hypothesis - I could not even answer them.” (HCWs, Ankara)
Freedom of Choice
Parents have the right to choose whether to immunize their child	“It is accepted that vaccination is not mandatory due to the verdict confirming that parents have freedom of choice.” (Ankara) “A decision of the Constitutional Court, ‘vaccine is an individual right, it does not affect public health,’ accelerated objections of families.” (Amasya)
Refugees
	“Some parents do not even know the birth date of their children, and children may be undernourished or born prematurely, so we cannot even calculate their age.” “We talk with parents with the help of an interpreter. We cannot get detailed histories of children, we cannot provide the necessary information about the vaccine.”