International Journal of

Environmental Research
and Public Health

Article
Opinions and Knowledge of Parents Regarding
Preventive Vaccinations of Children and Causes of
Reluctance toward Preventive Vaccinations
Anna Lewandowska 1, * , Tomasz Lewandowski 2 , Grzegorz Rudzki 3 , Sławomir Rudzki 4 and
Barbara Laskowska 1
1 Institute of Healthcare, State School of Technology and Economics, 37-500 Jaroslaw, Poland;
barbara.laskowska917@gmail.com
2 Institute of Technical Engineering, State School of Technology and Economics, 37-500 Jaroslaw, Poland;
tom_lew@interia.pl
3 Chair and Department of Endocrinology, Medical University of Lublin, 20-059 Lublin, Poland;
grzegorz.rudzki@orange.pl
4 Chair and Department of General and Transplant Surgery and Nutritional Treatment, Medical University
of Lublin, 20-059 Lublin, Poland; slawomir.rudzki@umlub.pl
* Correspondence: am.lewandowska@poczta.fm; Tel.: +48-6987-57926




Received: 5 May 2020; Accepted: 22 May 2020; Published: 24 May 2020


Abstract: Background: Despite the stability of global vaccination coverage, over 19 million children
worldwide do not currently receive basic vaccines. Over the past several years, there has been a
dramatic drop in the number of vaccinated children worldwide. The implementation of the vaccination
program and the scope of protection depend on the parents or legal guardians, who decide whether to
vaccinate their child or not. Studies were conducted to assess parents’ knowledge, attitudes, and beliefs
about vaccines, as well as the role of healthcare providers in parents’ decisions. Methods: A population
survey was conducted in 2018–2019. Parents or legal guardians of the children were invited to
participate in the study during their visits to the clinic for healthy or sick children. The method used
in the research was a diagnostic survey. Results: According to the conducted research, men and
women constituted 45% and 55% of participants, respectively. The average age of men was 44,
while, for women, it was 41. Internal research showed that as much as 71% of parents declared the
need for vaccination, although 41% of parents vaccinated their children according to the vaccination
calendar. The most frequently mentioned concerns included the possibility of adverse vaccination
reactions (22%), the occurrence of autism (7%), and child death (6%). General practitioners had,
by far, the greatest impact on the use of protective vaccination in children (73% women and 80% men),
although there were cases of discouraging the performance of compulsory vaccinations (41%),
and mentioning a doctor (38%) or nurse (3%). Conclusions: Modifiable determinants of the negative
attitude toward vaccinations are caused mainly by the lack of knowledge. These obstacles in
vaccinations can be overcome by improving health education in terms of the vaccination program.

Keywords: vaccinations; vaccination program; infectious diseases; parents’ attitude

1. Introduction
The course of infectious diseases is not always mild, and there is always a risk of serious complications
and even death, particularly in younger children. Therefore, the development of preventive vaccinations
is considered as one of the greatest achievements of modern medicine. Vaccinations are currently
the most effective method of preventing infectious diseases, reducing morbidity and the number
of complications and deaths, and allowing complete elimination of the disease. According to the

Int. J. Environ. Res. Public Health 2020, 17, 3694; doi:10.3390/ijerph17103694 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 3694 2 of 13

World Health Organization, vaccinations prevent 2–3 million deaths worldwide annually [1–3].
Protective vaccinations are recommended for all children. Therefore, their safety is the highest priority
and duty of social policy. Before registration, all modern vaccines undergo thorough, meticulous,
and reliable safety testing supervised by institutions established in individual countries. In Poland,
vaccinations undergo safety testing by the Office for Registration of Medicinal Products, Medical Devices,
and Biocidal Products; in Europe—the European Medicines Agency (EMA) and, established by the
World Health Organization, the Global Advisory Committee on Vaccine Safety (GACVS); and in the
United States—the Vaccine Adverse Event Reporting System [4,5]. Despite the stability of global
vaccination coverage, over 19 million children worldwide do not currently receive basic vaccines.
Over the past several years, there has been a dramatic drop in the number of vaccinated children
worldwide. Recent studies estimate that about one in eight children up to the age of two in the United
States are undervaccinated due to their parents’ choice, and most doctors report at least one refusal to
vaccinate per month [6–8]. Also, in Poland, a growing tendency to avoid vaccination has been observed.
In 2011, the parents’ refusal was the reason for not vaccinating about 4700 children, and in 2014,
over 12,000 parents refused to vaccinate their children. In 2017, this number increased to over 30,000
children [9,10]. The implementation of the vaccination program and the scope of protection depend on
the parents or legal guardians, who decide whether to vaccinate their child or not. Their decision may
result in vaccination being delayed or even refused. The increasing number of unvaccinated children is
likely due to parents’ concerns about the alleged negative impact of vaccines on health, as well as the
availability of unreliable information propagated by the antivaccination movement [11–14]. Trying to
understand the attitudes of parents, their opinion on vaccinations, and the reasons for the decision not
to vaccinate their child will allow extensive and appropriately targeted educational activities to be
planned and aimed at protecting child’s health through vaccination.

2. The Objective of the Work

The study aimed to assess parents’ knowledge, opinions, views, and attitudes about preventive
vaccinations, as well as to analyze how healthcare providers impacted the parents’ decision-making.

3. Material and Method

3.1. Study Design

A population survey was conducted in the Podkarpackie Voivodeship in the Clinical Voivodeship
Hospital in Rzeszow, the Healthcare Centre in Jarosław, and Primary Care facilities in Przemysl,
Jarosław, and Rzeszow districts in 2018–2019. The main indicator of participation in the study was the
age of children, which was between 10 and 14 years, since the majority of compulsory vaccinations
were already carried out according to the current vaccination calendar. The Preventive Vaccination
Programme (PSO) is the main source of recent information regarding vaccinations in Poland, and it
is published annually by the Chief Sanitary Inspector. The Ministry of Health in Poland aims at the
implementation of the compulsory vaccination scheme among children using free vaccines funded by
the government budget using non–reimbursed combination vaccines and recommended vaccinations
against certain infectious diseases included in services paid by caretakers. Doctors and hospital
personnel are obligated to provide parents with detailed information regarding compulsory and
accessible methods of immunoprophylaxis for their children. The current PSO includes following
compulsory vaccines: Tuberculosis (vaccination performed before the child leaves the neonatal unit),
diphtheria, pertussis, tetanus (the complete vaccination consists of 4 doses of the vaccine, the first
vaccination takes place at the age of 6 to 8 weeks, the second and third at 3–4 months and 5–6 months,
and the fourth at 16 to 18 months), measles, rubella, mumps (the first vaccination takes place at the
age of 13–14 months, the second at one year), poliomyelitis (the first dose takes place at 3–4 months
of age, the second dose at 5–6 months, the third dose at 16–18 months, and an additional dose at
the age of 6 years), hepatitis B (the full vaccination cycle includes 3 doses applied in the ages of 0, 1,
Int. J. Environ. Res. Public Health 2020, 17, 3694 3 of 13

and 6 months), and infections caused by Haemophilus influenzae B (the full vaccination cycle includes
3 doses applied every 4–8 weeks and an additional dose at the age of 2 years, the first vaccination
at 6–8 weeks of age), as well as vaccinations against pneumococcal infections (the full vaccination
cycle consists of 3 doses, the first one is applied at the age of 2 months, and doses continue until
the age of 5 years). The prevention is complemented by following recommended payable vaccines:
Meningococcal infections, chickenpox, rotaviruses, hepatitis A, meningitis, influenza, and human
papilloma virus. Parents or legal guardians of the children were invited to participate in the study
during their visits to the clinic for healthy or sick children. Each invited person was informed about
the purpose of the study. The respondents were given the opportunity to complete an online survey or
its paper version.

3.2. Sample
The study covered 2300 people residing in the Podkarpackie Voivodeship, 1265 women (55%) and
1035 men (45%). Most of the respondents lived in the city (68%), the remaining persons were rural
residents (32%).

3.3. Method
The method used in the research was a diagnostic survey, and the technique used was surveying.
The research tool was a survey questionnaire. The main part of the questionnaire included questions
about parents’ knowledge of current vaccination schedules, vaccine side effects, the presence of
contraindications for vaccination, the vaccination qualification procedure, and vaccination safety, as well
as preferred sources of information and the role of healthcare professionals in providing information
on vaccination and in deciding whether or not a child should be vaccinated. The questionnaire was
verified by testing a group of 100 parents in Poland within a month.

3.4. Ethical Considerations

The study was approved by the WMU Bioethics Committee (KB 386/2009). Participation in this
study was voluntary and anonymous, and respondents were informed of their right to refuse or
withdraw from the study at any time. Every respondent was informed of the purpose of the study and
the time of completion of the study.

3.5. Data Analysis

All data obtained were collected and analyzed using Prism 4.0. Descriptive statistics were used to
determine the percentages and 95% confidence interval (CI). Statistical characteristics of continuous
variables were presented in the form of arithmetic means, standard deviations, and medians. Statistical
characteristics of step and qualitative variables were presented in the form of numerical and percentage
distributions using the Student’s t-test or Mann–Whitney U test. A correlation was determined using
Pearson’s test, while χ2 was used for comparison between groups. Significance was assessed at p < 0.05.
The chi-square test was used to assess the diversity of opinions on vaccination safety in groups.
The repeatability of responses to individual questions was assessed using Kappa Cohen statistics.
Missing data were excluded from all analyses.

4. Results
According to the conducted research, women constituted 55% of participants (95% CI: 51–59),
and men constituted 45% (95% CI: 42–51). The average age of men was 44, while for women, it was 41.
Almost half of the surveyed women declared secondary education (48%, 95% CI: 41–50), vocational
education, (30%, 95% CI: 25–35), or higher education (22%, 95% CI: 19–30). Also, in the case of men,
secondary education predominated (43%, 95% CI: 38–47). Vocational education was declared by 37% of
respondents (95% CI: 31–41), and higher education was declared by 20% (95% CI: 16–26). Vaccinations
Int. J. Environ. Res. Public Health 2020, 17, 3694 4 of 13

carried out negatively correlated with both the age of parents (p < 0.0001) and the level of education
(p < 0.0001). Other descriptive statistics are included in Table 1.

Table 1. Descriptive statistics of the examined group of parents.

Total
Sex n = 2300
women (N/%) 1265/55%
men (N/%) 1035/45%
The age of Women
± standard deviation 41.2 ± 7.01
scope [23; 55]
median 41
95%CI [39.8; 41.8]
The age of Men
± standard deviation 43.8 ± 4.9
scope [27; 52]
median 44
95%CI [43.3; 44.0]
Place of Residence
city (N/%) 1564/68%
village (N/%) 736/32%
Financial Situation
very good (N/%) 184/8%
good (N/%) 1058/46%
average (N/%) 1012/44%
bed (N/%) 46/2%
Number of Children Owned
one child (N/%) 1265/55%
two children (N/%) 874/38%
three children (N/%) 161/7%
Women’s Education
higher education (N/%) 278/22%
secondary education (N/%) 607/48%
vocational education (N/%) 380/30%
Men’s Education
higher education (N/%) 207/20%
secondary education (N/%) 445/43%
vocational education (N/%) 383/37%

During the assessment of parents’ personal opinions about vaccinations, 71% (95% CI: 69–73)
responded favorably, declaring the need to perform them, 18% (95% CI: 13–23) responded indifferently,
and 11% (95% CI: 8–18) were against vaccinations. As many as 91% (95% CI: 88–92) of the respondents
believed that vaccinations have a significant impact on the child’s health, including as many as 35%
(95% CI: 23–37) who believed it is not a positive impact. More than half of the respondents believed
that the State should not impose the obligation to vaccinate children (53% of women and 51% of men,
95% CI: 52–60) while, 44% of women and 41% of men (95% CI: 41–48) claimed that vaccinations should
be voluntary, and 3% of women and 8% of men (95% CI: 1–19) had no opinion on this subject. A general
practitioner had the greatest impact on a parent’s decision to vaccinate, with 73% of women and 80%
of men (95% CI: 71–82) following their advice, 44% women and 41% of men claiming that vaccinations
should be voluntary, and 3% of women and 8% of men having no opinion on the subject. Other parents
declared completely independent decision–making (27% of women and 20% of men, 95% CI: 13–29).
According to parents, their independent decision was mostly influenced by research (31%, 95% CI:
23–37), their own feelings and beliefs (26%, 95% CI: 13–41), friends and family experiences (11%, 95% CI:
Int. J. Environ. Res. Public Health 2020, 17, 3694 5 of 13

8–18), their own experience (17%, 95% CI: 11–21), or possible side effects (10%, 95% CI: 8–16). As many
as 41% (95% CI: 39–48) of parents admitted that they had encountered the situation of discouraging the
performance of compulsory vaccinations, mentioning a doctor (38%, 95% CI: 31–44), friends and family
Int. J. Environ. Res. Public Health 2020, 17, x 5 of 13
(27%, 95% CI: 22–31), parents of children with vaccine adverse event (7%, 95% CI: 1–14), or a nurse
(3%, 95% CI:of1–11).
assessment parents’During the assessment
concerns of parents’
about vaccinations, more concerns
than halfabout
(58%vaccinations,
of women and more 68% than half
of men,
(58%
95% of CI:women
51–69)and 68% of men,
expressed 95% about
concern CI: 51–69) the expressed
allegedly concern
harmfulabout theof
effects allegedly harmful
vaccinations oneffects
their
of vaccinations on their children’s health, and in particular, of adverse
children’s health, and in particular, of adverse vaccination reactions (22%, 95 % CI: 20–29), autismvaccination reactions (22%, 95 %
CI:
(7%,20–29),
95% CI: autism
2–13),(7%,
and95% childCI:death
2–13),(6%,
and95% childCI: death
2–13).(6%, 95% CI: 2–13).
According to the According to the results
results of simple of
analysis,
simple analysis, the level of confidence in vaccination safety was associated
the level of confidence in vaccination safety was associated in a statistically significant way with a in a statistically significant
way
negativewith assessment
a negative assessment
of the occurrence of the occurrence
of vaccination of vaccination
complications. complications.
Educated people Educated people
perceived
perceived
vaccinations vaccinations
as less safeasthan less those
safe than
withthose
lowerwith lower
levels (p = 0.03). (p = 0.03).
levels of education
of education
During the analysis of the vaccination system
During the analysis of the vaccination system in the study group,in the study group, it wasitfound
was that
found 41% of parents
that 41% of
(95%
parents (95% CI: 37–46) vaccinated their children according to the calendar, 41% (95% CI:bought
CI: 37–46) vaccinated their children according to the calendar, 41% (95% CI: 37–46) 37–46)
combination vaccines to reduce the number of pricks, and 18%
bought combination vaccines to reduce the number of pricks, and 18% (95% CI: 13–25) did not (95% CI: 13–25) did not vaccinate
their children
vaccinate theiratchildren
all. As many as 40%
at all. As many (95%
as 40%CI: 39–44)
(95% CI: of39–44)
parents ofadmitted that theythat
parents admitted refused
they specific
refused
vaccinations (Figure (Figure
specific vaccinations 1). During the assessment
1). During the assessment of theofregularity of vaccinations
the regularity of vaccinations according
accordingto theto
vaccination calendar, 66% of women and 70% of men (95% CI:
the vaccination calendar, 66% of women and 70% of men (95% CI: 62–72) met the due dates, 26% of 62–72) met the due dates, 26% of
women
women and and 24%24% of of men
men (95%(95%CI: CI:19–32)
19–32)did didnotnotalways
always meet
meet due due dates,
dates, and and8%8% of women
of women andand6%
6%
of menof men
(95%(95% CI: did
CI: 4–7) 4–7)not did
meetnotthemeet the recommended
recommended vaccinationvaccination
dates. Asdates.
a reason Asfora reason for not
not complying
complying with this obligation,
with this obligation, parents mentioned
parents mentioned mild infectiousmild infectious
diseases of diseases
the childof the child
(71%, 95% (71%,
CI: 95% CI:
71–77),
71–77),
chronicchronic infectious
infectious diseases diseases
(35%,(35%,95% 95% CI: 31–41),
CI: 31–41), thethe occurrence
occurrence ofofconvulsions
convulsions after after previous
previous
vaccination
vaccination in a child (12%, 95% CI: 11–17), and 6% mentioned a lack of time (95% CI: 4–9). Among
in a child (12%, 95% CI: 11–17), and 6% mentioned a lack of time (95% CI: 4–9). Among
those
those whowho diddid not
not always
always or or did
did not
not comply
comply with with vaccination
vaccination dates,
dates, 72%72% of of parents
parents (95%(95% CI:CI: 69–79)
69–79)
vaccinated
vaccinated their their child
childas assoon
soonas aspossible,
possible,22% 22%(95%(95%CI:CI:19–25)
19–25)vaccinated
vaccinatedtheir theirchild
childafter
afterreceiving
receiving a
call from the Vaccination Center, and 6% (95% CI: 4–9)vaccinated their
a call from the Vaccination Center, and 6% (95% CI: 4–9)vaccinated their child according to their own child according to their own
availability
availability and and vaccinations
vaccinations were were performed
performed withoutwithout aa schedule. According to
schedule. According to the
the results
results ofof the
the
simple
simple analysis,
analysis, thethe level
level ofof confidence
confidence in in vaccination
vaccination safety
safety waswas statistically
statistically significant
significant in in relation
relation to to
the negative assessment of vaccination by professionals. Parents who
the negative assessment of vaccination by professionals. Parents who received a negative opinion on received a negative opinion on
vaccination
vaccinationfrom fromaadoctor
doctorwere were less
lesslikely
likelyto decide
to decide to vaccinate
to vaccinatetheirtheir
childchild
or refused vaccination
or refused with
vaccination
specific vaccines
with specific (p = 0.05).
vaccines (p = 0.05).

Figure 1. Refusal to vaccinate children.

Figure 1. Refusal to vaccinate children.
Int. J. Environ. Res. Public Health 2020, 17, x 6 of 13
Int. J. Environ. Res. Public Health 2020, 17, 3694 6 of 13
During the analysis of the use of optional vaccines, it was found that only 28% (95% CI: 19–31)
of surveyed parents confirmed the use of optional vaccines. The decision to buy the recommended
During
vaccines wasthe analysisby
motivated ofthe
thefear
use ofof falling
optional ill vaccines, it was found
and complications afterthat
the only
disease 28% (95%95%
(84%, CI: CI:
19–31)
81–
of surveyed parents confirmed the use of optional vaccines. The
89), advertisements (13%, 95% CI: 8–18), or doctor’s recommendation (24%, 95% CI: 19–31). Whendecision to buy the recommended
vaccines
buying awas motivated
vaccine by the
for their fear74%
child, of falling ill and (95%
of parents complications
CI: 71–79) after
tooktheinto
disease (84%,the
account 95% CI: 81–89),
price of the
advertisements
vaccine, 65% (95% (13%,CI:95% CI: took
63–72) 8–18),into
or doctor’s
account recommendation
knowledge about(24%, 95% CI:and
the vaccine, 19–31).
58%When(95% buying
CI: 54–
a62)
vaccine
took into for account
their child, 74%punctures
several of parentsat(95% one visitCI: 71–79) took into
and doctor’s account the price
recommendations (3%, of95%
the CI:
vaccine,
1–9).
65% (95% frequently
The most CI: 63–72) took into account
mentioned optional knowledge
vaccines about given the vaccine, were
to children and 58% the (95% CI: 54–62)(37%,
pneumococcal took
into account several punctures at one visit and doctor’s recommendations
95% CI: 28–39), rotavirus (25%, 95% CI: 21–32), meningococcal (20%, 95% CI: 13–25), and influenza (3%, 95% CI: 1–9). The most
frequently
(3%, 95% CI: mentioned optionalThe
1–5) vaccines. vaccines
reasongivenfor not to children were recommended
purchasing the pneumococcal (37%, 95%
vaccines wereCI: 28–39),
financial
rotavirus (25%, 95% CI: 88–92),
situation (90%, 21–32), fear
meningococcal
of side effects (20%, 95%95%
(32%, CI: CI:
13–25), andpoor
31–38), influenza (3%, 95%
information CI: 95%
(63%, 1–5)
vaccines. The reason for not purchasing recommended vaccines were financial
CI: 53–67), and doubts about the actual effectiveness of these vaccines (13%, 95% CI: 8–18). According situation (90%, 95% CI:
88–92), fear of of
to the results side effectsanalysis,
simple (32%, 95% theCI: 31–38), poor
frequency information (63%,
of nonobligatory 95% CI: for
vaccinations 53–67), and doubts
motivation was
about the actual
statistically effectiveness
significantly of thesewith
associated vaccines (13%, 95%
a negative CI: 8–18). of
assessment According
vaccination to the results
costs. of simple
People who
analysis,
considered thevaccinations
frequency of nonobligatory
expensive were less vaccinations for motivation
likely to vaccinate was statistically
their children significantly
with the recommended
associated
vaccine (p =with 0.05).a negative assessment of vaccination costs. People who considered vaccinations
expensive were less likely parents’
The study evaluated to vaccinate their children
opinions with the
about medical recommended
personnel and thevaccine (p = 0.05).
environment in which
The study
vaccinations wereevaluated
carriedparents’
out. Theopinions
waiting about time was medical
ratedpersonnel
positivelyand the environment
by 81% (95% CI: 78–84), in which
staff
vaccinations
courtesy by 81% were carried
(95% out. The
CI: 78–84), waiting
aesthetics of time was rated
the rooms by 86% positively
(95% CI:by 81% office
79–89), (95% equipment
CI: 78–84),
staff
withcourtesy
children’s by accessories
81% (95% CI: by78–84),
85% (95%aesthetics of the rooms
CI: 80–88), interest byin
86%the(95% CI:by
child 79–89),
85% (95%office CI:
equipment
80–88),
with children’s
efficiency accessories by
of performing 85% (95%
medical CI: 80–88),by
examination interest
75% in (95%the child by 85% efficiency
CI: 70–80), (95% CI: 80–88), efficiency
of performing
of performing
vaccination by medical
83% (95% examination
CI: 80–88), and by 75% (95% CI:in70–80),
competence providingefficiency of performing
information vaccination
on vaccinations and
by 83% (95%
possible CI: 80–88),
complications byand75%competence
(95% CI: 70–80). in providing information
For the degree on vaccinations
of satisfaction with theand possible
information
complications
received fromby the75% (95%about
doctor CI: 70–80). For the degree
the vaccination of satisfaction
schedule with the information
and vaccination effectiveness, received from
the results
the doctor about the vaccination schedule and vaccination effectiveness,
were as follows: 36% of parents (95% CI: 26–41) were very satisfied, 46% were satisfied (95% CI: 42– the results were as follows:
36% of parents
50), and 18% were (95% CI: 26–41) (95%
dissatisfied were CI:very satisfied, 46% were satisfied (95% CI: 42–50), and 18% were
10–22).
dissatisfied (95% CI:knowledge
The parents’ 10–22). of preventive vaccinations was subsequently analyzed. The vast
The parents’
majority of surveyed knowledge
parentsof preventive
(76% of women vaccinationsand 56%was subsequently
of men, 95% analyzed.
CI: 64–60)The vast majority
declared good
of surveyedof
knowledge parents (76% of women
immunization and 56%
issues, partial of men, 95%
knowledge was CI: 64–60)by
declared declared
22% of good women knowledge
and 34% of
immunization
men (95% CI: issues, 19–41),partial
and 2% knowledge
of women wasand declared
10% of bymen
22% of women
(95% and 34%
CI: 1–16) didofnot men (95%knowledge
have CI: 19–41),
and
about2%preventive
of women and 10% of men
vaccinations. (95%
The CI: 1–16) did
information notprovided
was have knowledge
mainly by about preventive
doctors (53%, vaccinations.
95% CI: 46–
The information
59) (Figure 2). was provided mainly by doctors (53%, 95% CI: 46–59) (Figure 2).

Figure 2. Sources of information about vaccinations.

Int. J. Environ. Res. Public Health 2020, 17, 3694 7 of 13

Int. J. Environ. Res. Public Health 2020, 17, x 7 of 13

The study showed that 95% of women and 89% of men (95% CI: 84–98) considered vaccines
The study showed
as supplements that 95%
that stimulate theofimmune
women and
system89%toofraise
menimmunity
(95% CI: 84–98) considered
(85% of women andvaccines as
86% of
supplements that stimulate the immune system to raise immunity (85% of women and 86% of
men, 95% CI: 84–98). Of the mild reactions that are likely to occur after vaccination, the most oftenmen,
95% CI: 84–98).
mentioned Of the
were fever (27%mild reactions
of women that
and 30% are
of likely
men, 95%to occur after redness
CI: 24–38), vaccination,
(24% the most often
of women and
mentioned
26% of men,were
95% fever (27% and
CI: 19–30), of women
edemaand 30%
(23% of men, and
of women 95%24%
CI: 24–38),
of men,redness
95% CI:(24% of (Figure
19–30) women3).and
26% of men, 95% CI: 19–30), and edema (23% of women and 24% of men, 95% CI: 19–30) (Figure 3).

Figure 3. Parents’
Figure3. Parents’ knowledge
knowledge of
of possible
possible vaccination
vaccination reactions.
reactions.

As
As aa contraindication
contraindication forfor vaccination,
vaccination, thethe respondents
respondents mentioned
mentioned thethe child
child taking
taking ananantibiotic
antibiotic
(17%
(17% of women and 20% of men, 95% CI: 10–22), fever (16% of women and 25% of men, 95% 14–28),
of women and 20% of men, 95% CI: 10–22), fever (16% of women and 25% of men, 95% CI: CI: 14–
and
28), allergic reaction
and allergic after previous
reaction vaccine vaccine
after previous (73% of women
(73% ofand 51% ofand
women men,51%95%ofCI: 47–80).
men, 95%Vaccination
CI: 47–80).
qualification should be carried
Vaccination qualification should out
beby the doctor
carried out byaccording
the doctortoaccording
97% of respondents (95% CI: 94–99),
to 97% of respondents (95%
while 3% (95% CI: 1–4) believed that it should be done by parents. Most parents
CI: 94–99), while 3% (95% CI: 1–4) believed that it should be done by parents. Most parents (78% of women
(78% of
and
women76%andof men,
76%95% CI: 74–79)
of men, 95% CI: claimed
74–79) that unwanted
claimed vaccination
that unwanted reactionsreactions
vaccination do not always
do notoccur in
always
every
occur child, andchild,
in every that this
andisthat
an abnormal
this is an reaction
abnormal of reaction
the bodyofafter
the vaccination. The most commonly
body after vaccination. The most
reported symptoms of vaccine adverse event were respiratory symptoms
commonly reported symptoms of vaccine adverse event were respiratory symptoms (21%, 95% CI: 10–20), autism
(21%, 95% CI:
(15%,
10–20),95% CI: 10–22),
autism and convulsions
(15%, 95% CI: 10–22), and(23%, 95% CI: 19–30)
convulsions (23%,(Figure
95% CI:4).19–30) (Figure 4).
Of the participants, 74% of women and 61% of men (95% CI: 59–79) had heard of combination
vaccines. According to them, combination vaccines are new generation vaccines (43% of women and
40% of men, 95% of CI: 39–47), vaccines that reduce the number of punctures (92% of women and 90%
of men, 95% CI: 89–97), vaccines immunizing against several infectious diseases simultaneously (68% of
women and 54% of men, 95 % CI: 49–70), and safer than traditional vaccines (13% of women and
19% of men, 95% CI: 9–22). In the studied group, there was a very strong positive linear relationship
between the source of knowledge and knowing about preventive vaccinations (+0.993), meaning that
people acquiring knowledge directly and from reliable sources, i.e., from medical personnel, presented
a higher level of knowledge.
The study attempted to analyze the occurrence of vaccine adverse events in the children of the
respondents. According to 78% (95% CI: 75–81) of respondents, adverse vaccination reactions occurred.
As many as 37% (95% CI: 35–39) did not remember the duration of the adverse vaccination reaction.
In 8%, the vaccination reaction lasted 24 h; according to 12% (95% CI: 9–14), it could be observed for
3 days; according to 10% (95% CI: 7–11), it occurred for 7 days; 15% (95% CI: 14–17) replied that the
symptoms lasted a few weeks; and 19% (95% CI: 15–20) reported that symptoms lasted a few years.
The symptoms mentioned by parents were high fever (23%, 95% CI: 21–25), neurological disorders

Figure 4. Parents’ knowledge of possible vaccine adverse event.

 As a contraindication for vaccination, the respondents mentioned the child taking an antibiotic
(17% of women and 20% of men, 95% CI: 10–22), fever (16% of women and 25% of men, 95% CI: 14–
28), and allergic reaction after previous vaccine (73% of women and 51% of men, 95% CI: 47–80).
Vaccination qualification should be carried out by the doctor according to 97% of respondents (95%
CI: 94–99), while 3% (95% CI: 1–4) believed that it should be done by parents. Most parents (78% of
Int. J. Environ. Res. Public Health 2020, 17, 3694 8 of 13
women and 76% of men, 95% CI: 74–79) claimed that unwanted vaccination reactions do not always
occur in every child, and that this is an abnormal reaction of the body after vaccination. The most
commonly
(14%, 95% CI: reported
12–16), symptoms
autism (6%,of95% vaccine adverse
CI: 5–8), event were
convulsions respiratory
(20%, symptoms
95% CI: 18–21), (21%, 95% CI:
and developmental
10–20), autism
disorder (18%, 95%(15%,CI:
95% CI: 10–22), and convulsions (23%, 95% CI: 19–30) (Figure 4).
17–20).

Figure 4. Parents’ knowledge of possible

Figure 4. possible vaccine
vaccine adverse
adverse event.
event.

5. Discussion
The introduction of common preventive vaccinations remains one of the greatest achievements
in public healthcare history. Routine vaccinations during childhood are crucial for the health of
individual people, as well as populational health. In Poland, preventive vaccinations are required
by law. People temporarily present in Poland are also required, according to the law, to receive
compulsory preventive vaccines included in the National Preventive Vaccination Programme. In case
a person is not fully able to take legal action, their legal guardian is required to fulfill the obligation.
The Chief Sanitary Inspector announces the Preventive Vaccination Programme for a given year in
the Journal of the Ministry of Health, providing detailed instructions regarding particular vaccinations,
the current epidemiological situation, and WHO recommendations. The Programme is published
before 31st October in the year preceding the year of the Programme’s implementation. The scheme of
obligatory and recommended vaccinations is implemented according to the Programme. The costs of
vaccines and performing vaccinations are covered by the part of the government budget controlled by
the Minister of Health. The obligatory preventive vaccinations of insured citizens are performed by
the healthcare providers that have signed the contract with the National Health Fund. The costs of
obligatory preventive vaccinations for uninsured citizens are fully covered by the government budget.
Recommended vaccinations are voluntary and performed using fully payable vaccines recommended
by the Chief Sanitary Inspector. Due to performing preventive vaccination, the hospital personnel are
required to fulfill various law obligations. The performance of the obligatory preventive vaccination
needs to be preceded with a medical examination in order to eliminate contraindications for the
vaccination. The vaccination cannot be performed more than 24 h after the medical examination date
indicated on the certificate. Obligatory vaccinations are performed by doctors, nurses, and midwives.
Their duties include informing the patient or their legal guardian of the obligatory vaccination, as well
as informing about recommended vaccinations. Moreover, the doctor who suspects or recognizes the
occurrence of the adverse effect is obliged to report such event within 24 h to the District Sanitary
Inspector [15–18].
The state of preventive vaccinations of children in Poland is satisfactory. The percentage of
vaccinated children is higher than in many other countries of the European Union. It reaches the
target values approved by the World Health Organization, the United Nations International Children’s
Int. J. Environ. Res. Public Health 2020, 17, 3694 9 of 13

Emergency Fund, and the United Nations Children’s Fund. Despite the majority of children being
vaccinated, concerns regarding the safety and effectiveness of vaccines have caused growth in the
number of unvaccinated children due to their parents and legal guardians avoiding fulfilling the
vaccination obligation [15]. The research conducted by Pieszka (2016) showed that 86% of Polish
parents vaccinated their children according to the schedule [16], while the individual research showed
that 70.9% of parents expressed the need to vaccinate their children. However, 41.3% of parents
vaccinated their children according to the schedule. The percentage of avoiding vaccination varies
between countries, but the trend is generally increasing. The research conducted by Heininger U.
in Germany showed that 65.1% of respondents refused to vaccinate their children [19]. In the U.S.,
one in eight children by the age of two is insufficiently vaccinated, and in Australia, 92.2% of children
received vaccines in 2012. The percentage of avoiding vaccination has reached the highest level in
history—94.78% [6,7,20,21].
The individual research showed that, due to the high cost, only 28.4% of parents chose
recommended or combined vaccines. It has been confirmed by the research conducted by Pomian–Osiak,
which showed that the cost of combined vaccines was the reason of performing free vaccinations [17].
Also, Kochman and Rudzińska, as well as Pieszka, additionally analyzed the relation between the
number of children in the household and buying combined vaccines. It was stated that parents who
had one child use combined vaccines more often than parents of three or more children [16,18].
The reason for avoiding the vaccination of children, according to numerous authors,
is parents’ concerns. A review of the available literature showed that parents’ beliefs about the
possibility of serious vaccination reactions are important factors strongly associated with vaccination
fluctuations. Caregivers’ concerns mostly focus on the composition of vaccines, as well as on side
effects usually associated with their own negative vaccination experience. The first results of the
European project VACSATC, which aimed to track parents’ attitudes to vaccination in several European
countries, carried out in 2008–2009, showed a generally positive attitude of parents toward vaccination
in childhood vaccination programs [14,22,23]. The most frequently mentioned concerns included the
possibility of adverse vaccination reactions (22%), the occurrence of autism (7%), and child death (6%).
As shown in the research by Rogalska et al., the main reason for refusal of vaccination of children
was the concern about the adverse vaccine effect. The concerns were also related to the simultaneous
immunization of children against too many illnesses (34%) and safety of vaccines. (21%) [24]. Similar
opinions of parents about an excessive burden of the immune system due to vaccination were described
in the research by Heininger et al. [19] and Offit et al. [25]. Most often, younger parents with a lower
level of education vaccinate their children according to the calendar, which has been confirmed by
data from international literature, emphasizing that the level of parental education also contributed to
fluctuations [7]. Opel et al. found that parents with a higher level of education were almost four-times
more concerned about vaccine safety than those with a lower level of education [26]. Similarly,
Smith et al. found that refusing to accept all childhood vaccines was more common among parents
with higher education than those with lower education [27]. Paulussen et al. showed that higher
levels of education had a predictive character in case of the negative intention of vaccination [28]. Also,
Opstelten et al. found a greater frequency of refusing vaccination among the educated parents [29].
The lack of knowledge about the benefits of vaccination, as well as incorrect information published
on the Internet, can influence the parents’ decision to not vaccinate their children. As studies
have shown, parents’ fear may be due to the increasing activity of antivaccination movements and their
frequent campaigns presenting vaccines as harmful. This has also been confirmed by data published
by the Polish State Sanitary Inspectorate, which shows that, for every third unvaccinated child (32%),
the parents’ decision was influenced by antivaccination movements [19,20,23,30]. In recent years,
many hypotheses have been formulated, of which there is no scientific evidence. They are related
to the impact of preventive vaccinations on the occurrence of autoimmune diseases and autism.
The hypothesis of the autoaggressive effect of vaccines seems to be similar to the genes of microbial
and human proteins, which means that, during vaccination, the immune system mistakenly recognizes
Int. J. Environ. Res. Public Health 2020, 17, 3694 10 of 13

and, as a result, attacks its own antigens. The foundations of this theory have remained undocumented.
However, vaccination has been shown to protect against exacerbations and infections in patients with
autoimmune diseases. Further hypotheses have concerned the impact of vaccines on multiple sclerosis,
nephrotic syndrome, type 1 diabetes, or chronic arthritis. The Global Advisory Committee on Vaccine
Safety analyzed reports appearing in 2000–2002 regarding the relationship between the occurrence of
lymphocytic leukemia after hepatitis B vaccination. These reports have not yet been confirmed [31–33].
At the beginning of 1990s, Andrew Wakefield presented a concept of the alleged relationship between
the MMR vaccination and autistic disorders. After analyzing available unpublished studies, The Global
Advisory Committee on Vaccine Safety (GACVS) clearly stated that this concept was not confirmed.
In January 2010, The Lancet removed articles by Wakefield from their archive. Evidence supporting this
concept was found to be false and manipulated, while Wakefield was found to be a fraudster in a court
order [33–35]. The following report by Allan Philips focused on the suspected relationship between
neurodevelopmental disorders in children using thiomersal, an organic mercury compound showing
antiseptic and antifungal properties, which is a preservative used in vaccines in concentrations of
0.001–0.01% [36,37]. In 1999, the Public Health Service and the American Academy of Pediatrics
issued a statement calling for the removal of mercury preservatives from all vaccines given to children.
Research on the harmfulness of mercury compounds contained in vaccines has also been commissioned.
This raised general concern, even though the harmfulness of thimerosal has never been proven. It is
now known that there are no contraindications for the use of vaccines containing thimerosal in children
and adults, including women who are not pregnant. All studies have shown a lack of relationship
between thimerosal and autism [2,5,15,24]. As shown in the research by Facciola et al., the relative
acquaintance percentage of people affected by vaccination was 43.3%, but only 13.9% said they knew the
person directly. This discovery suggests that the idea of harmful vaccines is present among the public
opinion and is easily passed onto others, as indirect knowledge accounted for 29.4% [5]. According to
the internal research, as many as 78% of parents claimed that their children had adverse vaccination
reactions, but this was due to lack of knowledge about the distinction between vaccination reactions
that can occur after each vaccination dose and adverse reactions, which are pathological phenomena.
Parents have a responsibility to make decisions in the best interest of their children. Parents,
taking into account medical advice and statistical information on risk and benefits, do not decide to
vaccinate their child. The lack of sufficient information on preventive vaccinations often explains the
lack of trust in childhood vaccination programs. Usually, it is a lack of knowledge about the etiology of
infectious diseases that contributes to the development of so-called antivaccination movements. Various
healthcare professionals play a key role in communication with parents. According to Facciola et al.,
only 18% of doctors favored recommended vaccinations, while 47.5% were opposed to vaccines [5].
Internal research has not confirmed this tendency, as General Practitioners have, by far, the greatest
impact on the use of protective vaccination in children (73% women and 80% men), although there
were cases of discouraging the performance of compulsory vaccinations (41%), and mentioning a
doctor (38%) and nurse (3%). Similar results were obtained by Heininger U., which showed that
GPs have the most significant role in educating parents regarding vaccinations. A GP, as the most
available and reliable source of information, is a person who has the greatest impact on the parents’
decision. Among 6025 respondents, 5722 (95.0%) mentioned their GP as the most important source
of information on immunization, before leaflets (48.0%), health magazines (44.7%), and the Internet
(38.7%) [19].
Insufficient contact with doctors and nurses, lack of reliable information from specialists regarding
safety, mechanisms and effectivity of vaccinations, and negative attitude are important factors
influencing parents’ attitude toward children vaccination, and they can even become the greatest
obstacle in vaccination implementation [2,24,38]. Although a randomized study by Wilson revealed
that neither evidence-based teaching nor presentations of polio survivors changed the chiropractics’
perception of vaccination, it is assumed that education and discussion with practitioners are ways
to increase the acceptance of vaccinations [4,39–43]. Therefore, healthcare professionals, as internal
Int. J. Environ. Res. Public Health 2020, 17, 3694 11 of 13

research has also shown, should provide complete information on the risks and benefits of immunization
and targeted diseases, as well as information on the effectiveness and risk of alternative methods,
including the refusal of vaccination. Information should be presented in a way that supports conscious
decision–making, which provides parents with the necessary basis to make accurate decisions [4,44–46].
Highly educated parents should choose such strategy to be their priority. Various research, including
individual research, has shown that educated people more rarely perceived vaccinations as safe,
compared to respondents with lover levels of education (p = 0.03). More effective cooperation with
the society is required, which can be achieved by providing reliable information and discussions.
In this field, the educational role of medical personnel is of the utmost importance. Due to their direct
contact with parents, medical workers are oriented in the current situation and have the possibility, as
well as the obligation, of educating the concerned parents and caretakers [9].

6. Conclusions
1. Modifiable determinants of the negative attitude toward vaccinations are caused mainly by
the lack of knowledge. These obstacles in vaccinations can be overcome by improving health
education in terms of the vaccination program.
2. The cost of combined and recommended vaccines is a significant financial obstacle for Polish
parents. That should convince Polish legislators to take into consideration at least partial
reimbursement of combined and recommended vaccines.
3. Regular monitoring of parents’ attitudes toward the vaccination program will allow for the
adjustment of educational programs to current needs.

Author Contributions: Conceptualization, A.L.; Formal analysis, A.L., T.L. and B.L.; Methodology, A.L., T.L.
and G.R.; Project administration, A.L. and S.R.; Software, T.L.; Supervision, G.R. and S.R.; Visualization, S.R.;
Writing—review & editing, B.L. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

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