Parental Vaccine Hesitancy in Early Childhood: A Cross‐Sectional Study from Türkiye Using the WHO‐SAGE Scale

1. Introduction

Most infectious diseases were fatal for many years until antibiotics were discovered. With the discovery and widespread use of vaccines, vaccine-preventable diseases have been brought under control, and deaths due to these diseases have begun to be prevented. Thanks to vaccines, many diseases such as smallpox have been eradicated; diseases with fatal complications such as measles, diphtheria, and tetanus have been brought under control. In recent years, trust in vaccines has been decreasing worldwide, and in our country, and vaccine hesitancy has been increasing [1,2]. In 2018, there was an increase in measles cases in Europe, highlighting the consequences of inadequate vaccination coverage. This trend has been exacerbated by long-standing vaccine hesitancy. Parental attitudes towards childhood vaccinations are changing, influenced by ethical, religious, and safety concerns, and vaccine hesitancy has increased significantly since the COVID-19 pandemic [3,4].

Due to misinformation, anti-vaccine campaigns and posts on social media platforms, vaccine hesitancy has become a major global health issue. In particular, reliance on social media platforms for vaccine-related information has been associated with higher vaccine hesitancy during the COVID-19 era. This has become evident with the spread of misinformation and conspiracy theories portraying COVID-19 vaccines as harmful during the pandemic. Similar patterns have been observed for other types of vaccines, including those for polio, measles, mumps and rubella, and diphtheria-tetanus-pertussis vaccines [5,6].

In a meta-analysis aimed to determine the worldwide prevalence of routine vaccine hesitancy among parents of children aged 0–6 years, the cumulative prevalence of parental vaccine hesitancy was found to be 21.1%. When the prevalence of vaccine hesitancy was stratified by WHO region, significant differences were observed, ranging from 13.3% in the Region of the Americas to 27.9% in the Eastern Mediterranean Region [7].

According to a study published in 2020 that examined the perceived importance, safety, and effectiveness of vaccines, low rates of confidence were detected in countries such as Afghanistan, Indonesia, Pakistan, the Philippines, Nigeria, and South Korea, and the same study also stated the rate of those who believe that vaccines are important, safe, and effective in Türkiye was 22.1% [8].

The aim of the study was to evaluate the attitudes of parents of children in early childhood (0-5 years old) towards vaccines and, in parallel, to investigate the reasons for vaccine hesitancy.

2. Material-Method

2.1. Study Design and Population

This cross-sectional study was conducted at the Department of Pediatrics, Prof. Dr. Cemil Taşcıoğlu City Hospital, University of Health Sciences, Istanbul, Türkiye, between April 15 and June 15, 2025. The study population comprised parents of children aged 0–5 years who visited the pediatric outpatient clinic during the study period.

Inclusion criteria: - Primary caregivers of children under 5 years of age who presented to the pediatric outpatient clinic - Primary responsibility for the child's care - Willingness to participate voluntarily in the study - Child had no diagnosed neurological and/or psychiatric disorders.

Exclusion criteria: - Caregivers of children aged 5–18 years - Individuals who were not the primary caregiver responsible for the child's care - Unwillingness to participate in the study - Child had a diagnosed neurological and/or psychiatric disorder.

2.2. Sample Size Calculation

The sample size was determined using the usual method for determining a population proportion, with an expected vaccine hesitancy prevalence of 22%, a margin of error of ±5%, and a 95% confidence level [8]. The determined minimum sample size was 263 people. The desired sample size was modified to 292 individuals to accommodate a projected 10% non-response rate. Consequently, our final sample of 403 participants surpassed the minimal requisite sample size and afforded sufficient statistical power for the study's aims.

2.3. Ethical Statement

Ethical approval was obtained from the hospital’s Non-Interventional Ethics Committee (Approval No: 133, dated April 14, 2025). The study adhered to the principles outlined in the Declaration of Helsinki. Before recruitment, all participants were informed of the study's objectives, methodologies, the voluntary nature of their participation, and the right to withdraw at any moment without repercussions. Written informed consent was obtained from all participants after they had the opportunity to ask questions about the study.

2.4. Data Collection

A total of 500 parents of children aged 0–5 years who visited the pediatric outpatient clinic were invited to participate. Of these, 403 parents completed the survey. The survey was administered using a face-to-face interview method. Each interview lasted approximately 15–20 minutes.

2.5. Data Collection Tools

The data collection tool consisted of three parts:

2.5.1. Sociodemographic Questionnaire

Included variables such as parent age, sex, education level, income level, number of children, and child’s age and gender. Considering that the minimum wage in our country for the period of January 2025 was 22,105 Turkish lira (TL), the hunger line was 25,000 TL, and the poverty line was 75,000 TL, the income level was scaled. According to a 5-point Likert scale, those with an income of less than 22,005 TL were considered as low, 22,005-25,000 TL as low-moderate, 25,001-50,000 TL as moderate, 50,001-75,000 TL as moderate-high, and 75,001 TL and above were considered as the high-income group.

2.5.2. WHO-SAGE Vaccine Hesitancy Scale (VHS)

A 10-item Likert-type scale, validated in Turkish. Items 1–4, and 6–8 relate to ‘lack of confidence’ and items 5, 9, and 10 to ‘risk factors’. Scores range from 10 to 50, with higher scores indicating greater hesitancy. Items 5, 9, and 10 were reverse-scored. The vaccine hesitancy scale questions were prepared according to the 5-point Likert method, and participants were asked to respond as follows: Strongly disagree (1), Disagree (2), Neither agree nor disagree (3), Agree (4), Strongly agree (5).

In a study conducted by the SAGE Vaccine Hesitancy Working Group, the Cronbach alpha values of the seven-item questionnaire measuring ‘lack of confidence’ and the three-item questionnaire measuring ‘risks’ were found to be 0.92 and 0.64, respectively. Scale scores range from 10 to 50, and there is no cut-off value [9,10,11]. In the Turkish validity and reliability studies, seven items (VHS-1-4,6-8) were grouped as ‘lack of confidence’ and three items (VHS-5,9,10) as ‘risk factors’. The Cronbach alpha value of the total items of the scale was 0.85. The Cronbach alpha value of Factor 1, ‘lack of confidence’, was 0.88. The Cronbach alpha value of Factor 2, ‘risks’, was 0.46. [12,13,14].

2.5.3. Vaccine Hesitancy Survey Questionnaire (VHSQ)

This tool consists of questions developed by WHO-SAGE that cover contextual, individual, and group, and vaccine/vaccination-specific influences. Most items were dichotomous (Yes/No), and some included open-ended components [9,10,11].

2.6. Statistical Analysis

The SPSS program (Version 28, Chicago, SPSS Inc., USA) was used for statistical analysis and data recording. In descriptive statistics, mean ± standard deviation (SD) for parametric values, median (median), minimum (min), and maximum (max) for non-parametric values, sample size (n), and percentage (%) values for frequency analyses expressing frequency were reported. The conformity of the data to normal distribution was tested using the Kolmogorov-Smirnov test. In comparing two groups, a variety of statistical tests were employed, depending on the nature and distribution of the data under investigation. Quantitative data were analyzed using tests such as the t-test, Mann-Whitney U test, Kruskal-Wallis test, or one-way ANOVA, while qualitative data were assessed using the Chi-Square test for independent groups and the McNemar test for dependent groups. Pearson or Spearman tests were used for correlation analysis, and linear or logistic regression tests were used in modelling. For statistical significance, a p-value below 0.05 was considered statistically significant.

3. Results

Of the 403 parents of children aged 0-5 years who were administered to polyclinics and completed the survey forms, 279 were female (69.2%) and 124(30.8%) were male. The mean age was 35.6 ± 6.3 years. Of the children, 199 (49.4%) were girls and 204 (50.6%) were boys. The mean age of the children was 23.7 ± 19.2 months (range: 1–60 months). The parents’ sociodemographic characteristics are summarized in Table 1.

The mean WHO/SAGE VHS score was 23.27 ± 11.74. The mean lack of confidence score was 14.97 ± 9.82, and the mean risk factor score was 8.38 ± 3.75 (Table 1).

Vaccine hesitancy scores differed significantly across sociodemographic groups. According to the education level, it was observed that vaccine hesitancy scores were lower as the education level increased. University graduates had significantly lower vaccine hesitancy scores than those with high school education or less (p<0.001). Income level also showed a strong association: the low-income group had significantly higher VHS scores than all other groups (p<0.001), while the high-income group had significantly lower scores (p<0.001). Additionally, it was observed that as the number of child participants had increased, their vaccine hesitancy scores increased significantly (p<0.001) (Table 2).

Contextual effects were examined, 27.8% (n=112) of parents stated that they were hesitant about vaccinating their children, and the rate of those who refused at least one of the recommended vaccines (private and free vaccines) for their children was found to be 20.6%. Of the parents, 11.4% (n=46) stated that they were hesitant about all free vaccines, and the most mistrusted vaccine among the free vaccines was the Mumps-Measles-Rubella (MMR) vaccine (76.6%). A total of 21.5% of parents (n=87) stated that the vaccine they did not trust the most was the mRNA-containing COVID vaccine and that they were hesitant about the vaccine due to its side effects.

Majority of participants (57.6%) stated that the news they heard/read in the media/social media did not affect their decision to vaccinate their child. Furthermore, 60.5% of the participants stated that they trust the government's vaccination policy. Of the participants, 57.6% stated that they knew someone who did not get vaccinated due to religious or cultural reasons, and 82.9% stated that they did not agree with this view. 18.9% of participants reported refusing the vaccine because they thought the vaccine would contain pork or other animal ingredients, and no statistical significance was found between male and female participants (p>0.05). Furthermore, a child's gender was found to influence vaccination decisions more in men than in women (p<0.05) (Table 3).

Differences according to gender were noted in vaccine hesitancy trends. Regarding media and social Influences, the rate of media and social media news stories influencing vaccination decisions was found to be significantly lower in men than in women. Furthermore, men were significantly more likely than women to have access to healthcare and to avoid vaccination for reasons such as availability of health centers, distance, or cost (p<0.05).

Individual and group effects were examined, 28.5% of the participants stated that they or a relative had experienced a bad reaction to the vaccine, and this situation negatively affected 25.3% of their vaccination decisions. Additionally, 36.2% stated that they did not think they received enough information about vaccines and their safety, and 81.1% stated that they wanted to obtain more information about vaccines from the Family Health Center. No statistical significance was found between male and female participants. (Table 4).

Regarding knowledge and awareness, men had a more positive view than women in terms of door-to-door or mass vaccination campaigns to alleviate concerns and provide sufficient information. Regarding vaccine acceptance and implementation, men had a lower rate of having friends who vaccinated their children compared to women, and their own rate of vaccinating their own children was also significantly lower (p<0.05).

Concerning vaccine-specific attitudes, 56.3% of participants expressed worries regarding approval processes of new vaccines. Table 5 shows risk perception and acceptance rates for several vaccines, showing that the meningococcal vaccine has the highest acceptance rate at 77.2%, while the rotavirus vaccine has the lowest at 62.8%. No significant differences in genders were detected (p>0.05).

Male participants exhibited significantly decreased risk perception for HPV, diarrheal illness, and COVID-19, resulting in proportionally reduced acceptance rates for HPV, rotavirus, and COVID-19 vaccines (p<0.05).

4. Discussion

This study examined vaccine hesitancy among parents of young children in Istanbul, Türkiye.

Vaccine hesitancy scores (lack of confidence and risk factors) were negatively correlated with income and education levels, and positively correlated with the number of children.

Similar to our study Sarıkahya et al. [15], found that the mean VHS scores of participants living in a high socioeconomic status (SES) region of Türkiye were found to be significantly lower. These findings emphasize that socioeconomic status should be taken into consideration in the process of informing parents.

Our findings contradict those of Soysal et al., who reported higher vaccine hesitancy among more educated and affluent parents in Türkiye, with a mean VHS score of 1.68 ± 0.53[16]. In contrast, vaccine hesitancy scores were significantly higher in the low-educated and low-income groups in our study. Moreover, unlike their study, we found no age-related differences in vaccine hesitancy.

Bulut et al. found that VHS scores of low-educated mothers and fathers were significantly lower than those of other groups. VHS scores were negatively correlated with parental age, age of last child vaccinated, birth order of children, and number of children [17]. Low-educated parents had significantly higher VHS scores than other groups in our study, and we observed that VHS scores increased with the number of children. These findings suggest that having multiple children may amplify parental concerns about vaccination.

In another study, it was found that as the income level of the participants increased, their knowledge levels also increased, and that there was a statistically significant difference in the knowledge scores about vaccines according to the parent who decided to vaccinate their child. It was also determined that the total attitude scores of the participants towards the vaccine showed a statistically significant difference according to their monthly income [18]. Similarly, in our study, as the monthly income level increased, the vaccine hesitancy scores were found to be significantly lower, and a more positive attitude towards vaccines was observed. This pattern shows that socioeconomic difficulties could limit access to correct vaccine information and increase hesitation.

In Karataş et al.’s study, 71.4% of parents stated that they decided not to vaccinate their children after one or more vaccinations, and 23.8% stated that their attitudes towards vaccination changed positively after COVID-19. It was determined that being a mother or father, education level, and number of children significantly affected the VHS score [19]. According to our findings, 39% of participants stated that they refused the COVID-19 vaccine, while 74.4% stated that they would complete routine childhood vaccinations for their future children. This clearly shows us that families have trust issues regarding COVID-19 vaccines.

Concerns about vaccine safety appeared as a significant theme in several studies. Sahoo et al. observed vaccine hesitancy in 9.18% of the participants. In this study, only the child’s age was found to be significantly associated with vaccine hesitancy, with almost half (48.5%) of the participants being concerned about serious side effects of vaccines and one-third (30.6%) stating that newer vaccines are associated with higher risks than older vaccines. Caregivers believed that vaccines were no longer necessary for rare diseases [20]. In our study, 68.7% stated that they were concerned about vaccine side effects, 56% stated that new vaccines were not well controlled, and 30.8% believed that vaccination for rare diseases was no longer necessary.

In Dörtkardeşler et al.’s study evaluating parents' attitudes towards COVID-19 vaccines, the vaccination rate was found to be 70.3%, while parents' intention to vaccinate their children was found to be 69.0%. While 88.3% of parents stated that they were knowledgeable about COVID-19 vaccines, 89.4% of parents stated that vaccination was necessary for the COVID-19 pandemic [21]. In Yılmazbaş et al.’s study, the pandemic process was found to have positively affected people's views on vaccine hesitancy [22]. In our study, 61% of the participants stated that they were vaccinated against COVID-19, while 60.8% stated that neither they nor their children were at risk of COVID-19 infection.

In our study, 63.8% of families reported not receiving sufficient information about vaccines and vaccine safety, while 81.1% reported seeking information from the Family Health Center. In a study families reported that they mostly received vaccine information from a Family Health Center nurse or physician (84.1%) [23].

In a study by Yilmaz et al., it was found that 81.6% of the parents considered it necessary to vaccinate their children, 83.1% had their children vaccinated with all the vaccines recommended by the Ministry of Health, 76.9% had missed some of the recommended vaccines due to the side effects of the vaccines, and 25.7% were hesitant to vaccinate their children [24]. In our study, 79.6% of the participants stated that the Ministry of Health's vaccination calendar was necessary, 79.4% stated that they had received all the recommended vaccines, and 20.6% stated that they were hesitant about vaccination.

This study has several limitations. The cross-sectional design prevents causal inferences regarding the links between sociodemographic characteristics and vaccine hesitation; longitudinal studies are necessary to determine time-based relationships and connections. The data were gathered from a single tertiary care hospital in Istanbul, constraining the applicability of the findings to other locations in Türkiye. Additionally, all data were self-reported, therefore susceptible to social desirability bias, especially with vaccination habits and attitudes.

5. Conclusions

According to the total score average of our study, participants were generally hesitant or had negative attitudes towards vaccination. The level of trust may have been low, or the perception of risk may have been high.

In general, it could be said that there was hesitation or anxiety towards vaccination in the participant group. When the lack of confidence score was examined, it was seen that participants had serious doubts about the reliability, benefits, and accuracy of the vaccination authorities. Trust in vaccination was quite low and trust needed to be established. While the risk factor score showed a medium-high level of risk perception, when evaluated together with the total score, it was seen that there was significant hesitation towards the side effects of vaccines.

According to the results of our study, vaccine hesitancy was at a moderate level, and it was necessary to increase parents' trust in vaccination, strengthen information sources, and provide scientific explanations for their fears of side effects. Strategies such as education, providing information, and enhancing communication with healthcare personnel could be recommended.