Knowledge and Attitudes on Pediatric Vaccinations and Intention to Vaccinate in a Sample of Pregnant Women from the City of Rome

Several studies have highlighted the role that population clusters of hesitancy and anti-vaccination sentiment may play in lowering herd immunity and contributing to disease outbreaks. In 2014, the coverage for polio, diphtheria, tetanus, and hepatitis B in Italy had already fallen below the recommended threshold of 95%; this downward trend was confirmed in the following years. Evidence shows that this decrease in paediatric immunisation rates is largely due to an increase in scepticism about the efficacy and safety of vaccines. These researchers sought to identify the degree of such scepticism, and the factors driving it, among a sample of pregnant women in the City of Rome. The ultimate aim was to obtain a picture of vaccine hesitancy and its determinants in the specific population of pregnant women surveyed and to facilitate the design of tailored strategies to increase trust in immunisation.

In 2017, Italy experienced an outbreak of measles, with 5,098 cases reported up to December 2017, 95% of which occurred among unvaccinated individuals or individuals vaccinated with only 1 dose; there were 4 deaths. In response, the Italian Parliament approved a law in July 2017 (no. 119/2017) obliging all preschool pupils (aged 0-6) to be immunised against 10 diseases. Data on 2017 vaccination coverage suggest the new law is working: For example, polio immunisation rates show a national average of almost 95%, with 11 of the 22 regions reaching the threshold of 95%. "However, this legislative measure by itself will not be sufficient to guarantee the compliance among preschoolers, since education in this age group is not compulsory. Introduction of this law may also be counterproductive if it decreases trust in health institutions among the large group of hesitant parents, thereby worsening the polarization in opinion on vaccination....A lively debate about the mandatory vaccination policy is currently ongoing in Italy, with the newly established Government discussing the possibility of revising law 119/2017. Within this context, the development of initiatives aimed at increasing the trust of Italian citizens in vaccination is of paramount importance."

From April 2016-April 2017, the researchers conducted a cross-sectional survey of pregnant women attending antenatal classes (corsi di accompagnamento alla nascita - CANs) organised by the family health centres of the City of Rome's Local Health Units (Aziende Sanitarie Locali - ASL). A specific questionnaire was developed for this purpose, based on a review of the literature on existing tools to assess vaccine hesitancy in parents and on the determinants of vaccine hesitancy. The choice of the population of pregnant women was driven by the observation that the antenatal period is when attitudes and beliefs about childhood vaccines first take shape. The study was conducted prior to the approval of law 119/2017and was intended to provide evidence to underpin the development of strategies aimed at increasing vaccine acceptance among the general population, in addition to restrictive policy measures.

More than 26% of the 458 respondents (all in their third trimester) showed a good level of knowledge of the safety and efficacy of vaccines, and almost 30% rated their own level of knowledge on vaccinations at least adequate. The most frequently reported source of information on vaccinations was word of mouth (62.6% of the sample), followed by traditional media, such as TV and newspapers (33.6%). Unofficial web sources (e.g. blogs, forums, non-institutional web sites) were consulted with approximately the same frequency as institutional sources (21.1 vs. 19.1%). Almost 38% of respondents (169/441) obtained information on vaccination from a health professional, mainly from general practitioners or primary care paediatricians (25.1%), indicating a satisfactory quality of the information provided (i.e., adequate or better) in 78.9% of cases.

All that said, one of the main findings is that relatively few of the women surveyed understand the risks that are associated with vaccine-preventable disease. Approximately 14% and 12% of women, respectively, indicated they do not consider measles and rubella vaccination useful, percentages that reflect the vaccination coverage recorded in Italy for these diseases in recent years. These data suggest the need to develop intervention strategies aimed at increasing awareness of the importance of available vaccinations.

Furthermore, rather high rates of agreement were observed with statements reflecting common anti-vaccination themes: For instance, 22.9% of respondents (101/441) disagreed that substances contained in vaccines are not dangerous to humans, and 14.0% (62/442) agreed that vaccines could cause diseases, such as autism, multiple sclerosis, or cancer. Only 75% of women were sure about vaccinating their children with the hexavalent vaccine, and 64.3% with measles, mumps, and rubella (MMR). Most respondents agreed with the importance of vaccines for the prevention of potentially serious diseases (90.8%, 404/445) and for the protection of the health of the community (82.3%, 363/441); at the same time, more than half of respondents reported concern about the side effects of vaccination (53.8%, 238/443), with over 45% of women agreeing with the statement that doctors often provide biased information on the risks associated with vaccinations (45.6%, 200/439). Respectively, 23.6% (104/440) and 38.6% (170/440) of respondents agreed with or were uncertain about the statement that vaccines are above all an economic deal for pharmaceutical companies.

Attitudes towards compulsory vaccinations were also explored: 17.8% (77/433) of women surveyed agreed that mandatory vaccinations are against the right of citizens to choose their own healthcare, while only 55.6% of the sample (245/441) indicated they would vaccinate themselves or their children if the vaccinations were no longer mandatory.

Multivariate analysis showed that a higher age, having a university degree, perception of the quality of the National Health Service (NHS) as good or excellent, and having received information on vaccinations from institutional websites or through education (e.g., school, university) were all associated with a higher level of knowledge of the safety and efficacy of vaccines. On the contrary, factors associated with a lower level of knowledge were the choice of populist movements as political orientation, preference for homeopathy vs. allopathic medicine, and having received information on vaccines by word of mouth.

A good level of knowledge was the strongest predictor of positive attitudes towards vaccination (odds ratio (OR) 11.61, 95% confidence interval (CI) 6.43-20.96), which, in turn, influenced the intention to vaccinate for most vaccines with the perception of the benefit of immunisation for protection against disease. In contrast, having had indirect experience of vaccination side effects and having received information about vaccination through the media (TV, radio, newspapers, etc) were not likely to result in a positive attitude.

Reflecting on the findings, the researchers observe that attitudes towards vaccination cannot be easily categorised into "pro-vax" and "anti-vax". Despite the perception that some infectious diseases represented a low risk to their child, most women participating in the survey were, in fact, positive about the importance of vaccination. At the same time, almost 80% of women declared themselves worried or uncertain about the side effects of vaccines and about the risks associated with the simultaneous administration of multiple vaccines. The same percentage of women agreed with or were uncertain about the statement that doctors provide biased or incomplete information on vaccine safety. The proportion of women who believe that vaccination is mainly in the economic interests of pharmaceutical companies was also high. Therefore, it would seem that women generally accept the concept of immunisation as a "social norm", but, at the same time, there is a low level of trust of available vaccines. These findings confirm the need to improve communication with citizens on vaccines and, more generally, to work to increase trust in health institutions.

In conclusion, scepticism about the safety, efficacy, and importance of vaccines is associated with pregnant women's hesitancy to vaccinate their children, suggesting the need to develop targeted strategies to increase vaccine acceptance in the antenatal period. The researchers suggest that these strategies should be dialogue based and should focus on strengthening the capacity of healthcare professionals, particularly midwives, and on securing the involvement of the media to deliver information correctly to future parents and thereby reduce fear about vaccine safety. The researchers are conducting a survey aimed at exploring the knowledge and attitudes of midwives belonging to the Board of Midwives of Rome Province, whose results, together with those emerging from the present study, will allow the development of context-specific education and communication interventions.