What does this article add?
- Less than half of the participants stated that they were confident in
the effects of the vaccine and would be vaccinated.
- There is a negative relationship between vaccine refusal and health
literacy.
- Accurate information is vital to fight vaccine rejection.
INTRODUCTION
The COVID-19 pandemic not only affected the health of individuals but
also brought many social and economic problems. Works to control the
pandemic and to reduce all these negative effects are continuing
worldwide.1 Since the beginning of the epidemic, false
information and fake news about COVID-19 started to spread rapidly,
confusing people. Beliefs in prevention and treatment from COVID-19
negatively affected, as well. In Iran, for instance, misinformation
about alcohol intake to eradicate the COVID-19 virus has resulted in the
deaths of hundreds.2 Previous studies have reported
that fake news may be at the center of vaccine
hesitancys.3, 4 Many conspiracy theories have been put
forward with the rapid spread of fake news and unidentified information
in society. Exposure to COVID-19 vaccine refusal conspiracy theories
also affects vaccination intention.5 Health literacy
(HL), a way of preventing the spread of misinformation in society,
affects people’s ability to access reliable information and make
informed decisions.6 HL is generally known to help
distinguish fake news.7
Practices such as the use of masks, cleaning measures, and social
distancing have come to the fore to prevent the COVID-19 pandemic. In
addition to this, the most important way to fight the epidemic seems to
be vaccination. However, ”vaccine hesitancy” is seen as an important
obstacle to attempts to control the pandemic. While many studies in the
scientific world have focused on the effectiveness of the vaccine
recently, the concepts of vaccine hesitancy and vaccine rejection appear
to be an important public health problem. WHO has identified ”vaccine
hesitancy” as one of the top ten threats to global health. Vaccination
programs can only be effective when they are accepted by large sections
of the population.8 Discussions about vaccination
applications have been coming up all over the world
recently.9 In addition to the current vaccine refusal
attitudes, concerns about the safety and effectiveness of the vaccine
have arisen due to reasons such as the emergence of the disease and the
rapid production of the vaccine.10 Regarding previous
vaccination practices, studies examining anti-vaccine websites have
found that the information on these sites underestimates the risk and
severity of diseases.11, 12 It is seen that these
vaccine refusal campaigns are increasingly continuing in the COVID-19
pandemic.13 Hence, it is of great importance that
people have access to correct and sufficient information in order to
cope with the problems related to vaccine hesitancy and vaccine refusal.
The World Health Organization (WHO) defines health literacy as ”personal
characteristics and social resources that enable individuals and
societies to access, understand, evaluate, and use the information to
make health-related decisions”.14 It is known that
poor health literacy in chronic diseases is associated with increased
healthcare expenditures and mortality.15 According to
a meta-analysis evaluating the relationship between health literacy and
infectious diseases, a low level of health literacy also affects
protective behaviors such as vaccination and hand
hygiene.16 With the emergence of the COVID-19
pandemic, it has emerged that health literacy is also important in
communicable diseases. Low health literacy scores are associated with
’vaccine hesitancy’.6, 17
With this study, we have aimed to evaluate the effects of having
inadequate or incorrect information, one of the possible determinants of
attitudes towards the COVID-19 vaccine. For this reason, we measured the
“health literacy” levels and “vaccine refusal” attitudes of people
and put forward the hypothesis that people with incomplete or incorrect
information would have more negative attitudes towards vaccination.
METHODS
Sample and Procedure
The forms for the study are sent online to 750 participants in total.
All participants are informed about the study. A total of 512 people
participated in the study. The results of 12 participants due to random
marking and 4 people due to short survey completion times (less than 15
minutes) are not taken into consideration and analyzes are conducted
with 496 participants in total.
Data Collection Tools
Sociodemographic Data Form
It is specially prepared for this study by the research team. It is a
form in which the demographic data of the participants such as age,
gender, occupation, and the preliminary opinions of the people about the
vaccination application are asked.
Turkey Health Literacy Scale-32 (THLS-32)
The scale is developed by the Republic of Turkey Ministry of Health in
2016 in line with the ”European Health Literacy
Survey-HLS-EU”.18 It consists of 32 questions in total
and consists of 2 dimensions, ”prevention from diseases/health promotion
and treatment/service”, and 4 processes
”accessing health information,
understanding health information,
evaluating health information and
applying/using health
information”. High scores indicate high health literacy.
Anti-Vaccine Scale
It is created to evaluate the factors related to vaccine
refusal.19 The scale includes 21 items and 4 factors:
”vaccine benefit and protective value, vaccine refusal, solutions not to
be vaccinated and legitimization of vaccine hesitancy”. High scores
indicate high vaccine refusal.
The ethical aspect of the research
In order to conduct the study ethics committee approval is obtained from
*** non-invasive clinical research ethics committee (Date: 05.04.2021,
Number: 13) Besides, permission is obtained from the authors who
developed the scales by e-mail. On the first page of the data collection
form, participants are presented with an information form describing the
study objectives and procedure (if the participants checked the ”I
understand the study and want to participate” box at the bottom of the
information form), and those who wanted to participate are enabled to
answer the survey questions.
Statistical Method
All data (categorically and continuously) are analyzed using the
Statistical Package for Social Science windows version 22.00 (SPSS) web
software. Quantitative data are evaluated as percentage mean and
standard deviation. Participants are grouped according to their
attitudes towards the vaccine, and normal distribution conditions are
evaluated using the Kolmogorov-Smirnov test. Categorical variables are
evaluated with the Pearson Chi-square test and mean scores of
independent variables between groups are evaluated with the Independent
Sample t-test. The Pearson Correlation test is used to evaluate the
correlations between scale scores. Multiple linear regression analyzes
are applied while evaluating the precursor factors of vaccine refusal.
For all analyzes, p<.05 is taken as a basis for significance.
RESULTS
A total of 135 male and 361 female participants are included in the
study. The socio-demographic characteristics of the participants are
shown in Table 1. Interestingly, while the participants whose turn is
vaccinated made up 63.7% of all participants, only 5.2% stated that
they are not vaccinated even though it is the time of vaccination, and
7.5% stated that it would not be vaccinated when it came to
vaccination. 42.1% of the participants stated that they trust the
effects of the vaccine and that they will be vaccinated.
The ages (p <.001) and years of education (p = .002) are found
to be significantly higher in those who are accepted to the vaccine.
Furthermore, it is found that the intention of vaccination is lower in
women than in men (p = .013). Lastly, it is determined that the group
with the low intention to the vaccine had higher scores on vaccine
refusal scales (p <.001) and lower HL scores (p = .008) (Table
2).
The relationships between the total and sub-dimension scale mean scores
of the participants against vaccination and the total and sub-dimension
mean scores of Health Literacy are shown in Table 3.
In the linear regression analysis, it is determined that education year
and age negatively predicted vaccine refusal scores (Table 4).
DISCUSSION
According to the results of our study, we have found a negative
correlation between vaccine refusal and health literacy, thus confirming
the main hypothesis of our study. In addition, we have found that the
negative predictors of vaccination opposition are not only health
literacy, but also education year.
In a study examining the articles between 2007 and 2017, it is found
that HL and vaccine hesitancy are associated with age, country, and
vaccine type.16 In this collecting, it is reported
that most of the studies originated from the USA and high-income
European countries, data on low-income countries are scarce, hence
geographical representation may be weak. Therefore, it is important to
present these studies from different countries. In fact, vaccine
hesitancy is also an important problem in the pre-pandemic period. A
study conducted in Italy in 2016 reported that 16% vaccine
hesitancy-vaccine refusal among parents.20 Studies
evaluating the relationship between the frequency of pneumococcal and
influenza vaccination and health literacy indicated that as the level of
health literacy increased, the vaccination rates
increased.21, 22 The significant relationship between
low health literacy and vaccine hesitancy has also been demonstrated by
COVID-19 studies.6 This finding is in line with the
findings of our study, in which we have found a negative relationship
between HL scores and vaccine refusal attitudes.
Currently, the most important approach in fighting the pandemic is the
vaccination of society. However, vaccine hesitancy-vaccine refusal is a
major obstacle to this situation. In the study conducted with 7664
people from seven European countries, 18.9% of the participants stated
that they are not sure about being vaccinated and 7.2% of them do not
want to be vaccinated.23 Despite the intervening
period of nearly 1 year, according to the results of our study, 7.5% of
the participants stated that they would not be vaccinated and 14.3% are
indecisive. In a previous study, 31% of the participants in Turkey
stated that they are ambivalent or negative about vaccination
administration.24 In the same study, this rate is
found to be 14% for the participants in the UK. In a study conducted
with 745 students in Italy, 13.9% of the participants stated that they
would not vaccinate or are indecisive.9 When the
studies in the literature are analyzed, it can be considered that the
vaccine instability-opposition attitudes in Turkey are higher than in
other European countries. Hence, it is extremely significant to reveal
the reasons for this attitude.
Having the right information is extremely important to fight vaccine
refusal attitudes. For instance, previous studies have shown
relationships between believing that the COVID-19 is an artificial virus
produced in the laboratory and vaccine refusal.24People’s interest in such conspiracy scenarios negatively affects the
prevention or treatment strategies. In particular, conflicting news in
the media regarding the effectiveness, reliability, and side effects of
the COVID-19 vaccine may cause vaccine hesitancy or vaccine refusal in
individuals. In this context, it is important to share clear and
reliable information about the vaccine in the media, which is the source
that individuals frequently use to access vaccine-related data. In a
recent study conducted with 1153 people in Germany, only 49.9% of the
participants are found to have sufficient HL.25 In the
study, it is reported that the lowest scores of the participants are
related to the capacity to “decide on the reliability of the
information in the media”. The relationship between misinformation and
vaccine hesitancy has also been highlighted in previous
studies.4
Another important finding of our study is the negative correlation
between age and vaccine refusal. This finding is consistent with the
results of the studies evaluating the relationship between age and
vaccine acceptance, resulting in lower vaccine hesitancy in the older
age group.26 This situation can be interpreted as the
elderly group preferred to be vaccinated with the risks rather than
getting the disease, due to the frequency/severity of getting COVID-19
and complications as the age increases. Therefore, for a successful
vaccination program, it should include non-formal education programs on
the safety and efficacy of the vaccine, especially for the untrained and
young age groups with high vaccine hesitancy.27 In
addition to this, it should be taken into consideration that it is
important to inform the public correctly; however, HL skills should also
be developed in order for the information to provide attitude
change.28 As the level of HL increases, it will be
possible for individuals to become aware of the reasons behind medical
advice and to evaluate the consequences of their
actions.29
Besides, a specific emphasis on the concept of ’vaccine literacy’ is
vital to understanding the determinants of attitudes towards vaccination
and enabling change of attitude.30 The Erice
Declaration, which is prepared in Italy to address issues related to
vaccine attitudes before the pandemic, emphasizes the promotion of the
concept of HL and vaccine literacy and the inclusion of the media in
this movement.31 Given the uncertainty created by the
pandemic and the confusion of information in the media, the concept of
vaccine literacy can be a fundamental basis for a way out from the
pandemic 32.