The impact of parents' health behaviours on their preferences regarding vaccinations

doi:10.21203/rs.2.20442/v1

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The impact of parents' health behaviours on their preferences regarding vaccinations

https://doi.org/10.21203/rs.2.20442/v1

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published 25 Jul, 2020

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Background. Health behaviours are very important factors of human life. Currently, as the number of vaccinated children in Poland and throughout Europe is decreasing, parents’ health behaviours may affect the frequency of vaccinations. The aim of this study was to assess the impact of parents’ preferred health behaviours regarding vaccinations.

Methods. The study was carried out using a diagnostic survey method with an original questionnaire and the Inventory of Health Behaviours. The study included 300 parents.

Results: The level of health behaviours was average in 42.3% of the respondents, low in 33%, and high in 24.7%. Convictions about immunity after contracting a disease, the need to vaccinate for all diseases, the vaccination system, the quality of the vaccines used in Poland, the universal obligation to vaccinate, and the admission of unvaccinated children to crèches and kindergartens were not statistically related to health behaviours. Significant differences in health behaviours, mainly the level of normal eating habits (p = 0.038) and positive mental attitude (p = 0.022), were found in relation to views on the toxicity of vaccines. Participants who reported that vaccines can cause autism engaged in a higher level of prophylactic behaviours. Respondents who vaccinated their children with combined vaccines had a significantly higher level of health practices. Significant or near-significant differences in health behaviour levels in various areas were found between those who sought the recommended vaccinations and those who did not.

Conclusions: The health behaviour levels of the majority of the respondents were average, and the most frequent category was "positive mental attitude.” Parents who believed in the toxicity of vaccines were more concerned about proper nutrition, had a positive mental attitude, and engaged in a higher level of preventive behaviours and health practices. Parents who did not vaccinate their children had lower levels of normal eating habits. Parents who vaccinated their children with additional vaccines had a higher level of health behaviours, especially in terms of health practices.

Pediatrics

Vaccinations

health behaviours

parents' opinions

Health behaviours comprise a very important element of human life that has been the subject of theoretical considerations and research by scientists from various fields for many years [1]. There are different concepts for defining and classifying health behaviours.

Health behaviours are a multifactorial set of reactions of social groups associated with treatment and healing agents and stimulated by the need to maintain health and life and prevent disease [2]. Steptoe et al. [3] distinguished several classes of pro-health behaviours including stimulant avoidance, transportation safety, eating habits, positive health practices, and behaviours associated with preventive activities. Many factors that affect both the individual and the environment influence the formation of health behaviours [4, 5].

‘Vaccine hesitancy’ is a new term used in last years to describe anyone who is doubtful about vaccinations or who chooses to delay or refuse immunizations even when they are readily available [6]. There are a wide range of factors that cause vaccine hesitancy including the compulsory nature of vaccines, their temporal relationships to adverse health outcomes, unfamiliarity with vaccine-preventable diseases, and lack of trust in public health agencies [7].

Reasons for refusing or delaying child vaccination reported by parents differ generally but can be classified into four categories: religious reasons, personal beliefs, safety concerns, and a desire for more information from healthcare providers [8].

According to the Polish National Institute of Public Health [9], in Poland in 2017, 98.0% of 2-year-olds, 98.6% of 3-year-olds, 95.5% of 7-year-olds, 93.3% of 11-year-olds, 93.7% of 15-year-olds, 91.7% of 20-year-olds, and 93.3% of girls aged 14 (rubella) received the recommended vaccines. Despite the high vaccination rate of children and adolescents in Poland, the number of unvaccinated children has been increasing since 2010. At that time, 2,437 people had evaded their duty to vaccinate, while in 2018, about 23,000 parents refused to vaccinate their children [10]. 2011–2014, the number of people who evaded compulsory immunization more than doubled from approximately 5,000 to over 12,000 people [11, 12].

A healthy lifestyle is comprised of the conscious or unconscious choices of a given individual, and vaccination is one of the most important health behaviours. Parental vaccination decisions are complex and multi-dimensional [13].

The family is the first and the most important institution for shaping both attitudes towards maintaining health and the behavioural patterns necessary to maintain health [14]. Parents serve as fundamental role models, although they are not the only examples available to children. School is another educational system available to children, and teachers are the next most important people involved in shaping health attitudes and behaviours [15]. Health is the result of many factors, among which family, school, the peer environment, customs and tradition, and individual lifestyles are equally important. The pro-health attitudes and behaviours formed during childhood will promote the further development of the individual and support him/her in subsequent stages of development, that is, during adulthood and old age[16–17].

The relationship between parental health behavior and child obesity, mental health, and physical activity is proven [18–20]. Several studies described the relationship between parents' health communication behaviors and vaccinations for children [21]. Furthermore, parents with high levels of communicative and critical health literacy are less likely to vaccinate their children [22]. However, there are no studies assessing the relationship between parental behavior and vaccination of children.

The aim of the study was to assess the association of parents’ health behaviors with children’s vaccinations.

The study was carried out from July 2015 to June 2016 using the diagnostic survey method [23], which is a method of gathering knowledge about structural and functional attributes and the dynamics of social phenomena, opinions, and views of selected communities and the severity and developmental directions of specific phenomena. The diagnostic survey method is often used in pedagogical, psychological, and social research to determine socio-educational phenomena. The most common techniques used in surveys are interviews, questionnaires, and document analysis. An original questionnaire included demographic data: parents age, gender, children age, place of residence, education, financial status, and questions about vaccination. The vaccination questions were following: vaccination children, immunization is the most effective method of protection against infectious diseases; vaccine safety, compulsory vaccination source of information on vaccination.

The Polish version of the Inventory of Health Behaviour (IHB) [24], with the use of several tools available for testing different health practices was used. The IHB is intended for the study of healthy and ill adults. It contains 24 statements describing various types of health-related behaviours and enables the determination of both a general indicator of the level of health behaviours and specific indicators for the following categories of behaviours: proper nutrition (mainly taking into account the type of food consumed - including the primary types of food consumed, e.g., whole wheat bread, vegetables, and fruits), preventive behaviours (regarding compliance with health recommendations and obtaining information on health and disease), health practices (daily habits regarding sleep and rest), physical activity (daily exercise habits and recreation), and a positive mental attitude (avoiding strong emotions, stress, depressing situations) [24]. The internal reliability of the IHB scale, based on Cronbach's alpha, is 0.85 for the entire inventory; for the four subscales, internal reliability ranges from 0.60 to 0.65. According to the author’s suggestions regarding the IHB scale, the scores for the health behaviour components were assessed as the average points for each subscale, while the total IHB score was determined by the sum of all obtained points. Thus, eating habits, preventive behaviours, positive mental attitude, and health practices can take values from 1 point (the worst result) up to 5 points (the best result), whereas the total scale score can range from 24 to 120 points, with higher scores indicating greater positive health behaviours.

Data analysis

The data management and analysis were conducted using Statistica version 13.0 (Statsoft, Tulsa, OK, USA). Descriptive analysis was performed by calculating frequencies and percentages of variables. Relationships between two variables were analysed using the chi-square independence test. Relationships among three groups were examined using the Kruskal-Wallis test. The critical level for all tests of significance was p < 0.05.

The study included 300 parents; 46.3% were aged 31-40 years, 30% were aged 18 to 30 years, and 23.7% were aged 41 to 50 years. In the studied population, 83% were women, and 17% were men.

A total of 54.3% of the respondents had at least some higher education, 37.3% had a secondary education, 7.3% had a vocational education, and 1% had a primary education. Most had children aged 2 to 4 years (40%), followed by 0-23 months (25.3%), 7-10 years (22.7%), 11-15 years (22.3%), 5-6 years (21%), and 16-18 years (13.3%). Most of the respondents (57.3%) declared that their financial situation was good. The vast majority of the surveyed parents (85%) were not professionally involved in health care. Only 15% of the respondents were in the medical profession.

The vast majority of parents (96.3%) declared that they vaccinated their children. Only 3.7% of the respondents did not vaccinate their children. According to 68% of parents vaccination is the best method of preventing infectious diseases. Similarly 63% of parents reported that vaccines are safe and 65% reported that vaccinations should be compulsory. Most of respondents (84%) said that a family doctor should be a source of information on vaccinations.

In the surveyed population, health behaviours (proper eating habits, preventive behaviours, positive mental attitude and health practices) were practiced at similar levels, although the most frequently occurring health behaviour was a ‘positive mental attitude’. Details are shown in Table 1.

The total IHB scale rates health behaviours on three levels: low, average, and high. This classification also takes into account the sex of the respondents, using slightly different criteria for women and men. Most of the parents (42.3%) had an average level of health behaviours; one in three respondents had a low level, and one in four had a high level. Details are provided in Table 1.

Next, the relationships among behaviour levels in the four areas specified on the IHB questionnaire was examined. The level of individual health behaviours was measured on a numerical scale. The analysis consisted of juxtaposing the mean IHB scores (with standard deviations) by group with the responses to the questions regarding vaccination and determining the significance of the relationship between them using the Kruskal-Wallis test. Opinions on immunity being infected with a disease were not related to the parents’ health behaviours. Opinions on the need to vaccinate for all diseases, the vaccination system, and vaccine quality were not related to health behaviours. Details are shown in Table 2.

Significant differences in health behaviour levels, particularly eating habits (p = 0.038) and positive mental attitude (p = 0.022), were found among respondents with different opinions on the toxicity of vaccines. Parents who believed that vaccines were toxic cared about proper nutrition had positive mental attitudes and a higher level of preventive behaviours and health practices than other parents. Respondents who believed that vaccines can cause autism had a significantly higher level of preventive behaviours than other parents. Opinions on the general obligation to vaccinate were not related to health behaviour levels in any of the four areas identified in the IHB questionnaire. Additionally, opinions on the admission of unvaccinated children to crèches and kindergartens did not relate to the respondents’ health habits. Details are shown in Table 3.

Parents who did not vaccinate their children with combined vaccines had a lower level of normal eating habits (p = 0.058). Parents who vaccinated their children with combined vaccines showed significantly higher levels of health practices (on average, 3.28 for this group compared with 3.12-3.13 in the other two groups). Significant or near-significant differences in levels of various health behaviour were found between those who used recommended vaccinations and those who did not. Parents who vaccinated their children also had a higher level of health behaviours, especially in the field of health practices. The remaining results are shown in Table 4.

In the current research, most parents reported an average level of health behaviours, and 25% reported a high level.

It is believed that greater health behaviour awareness in the family results in better the health effects for its individual members [25]. The present and future health of the family system and all its members depends largely on the parents' actions, decisions, conduct, choices, and preferred lifestyle. It should be noted that parents raise children based not only on scientific and popular science knowledge but also on colloquial knowledge. These types of knowledge may have a positive or negative influence on the development of family behaviour patterns, the introduction of modifications and changes in behaviours and the consolidation of previously understood attitudes, including those related to health [14].

In the currently studied population, all categories of studied health behaviours (proper eating habits, preventive behaviours, a positive mental attitude, and health practices) were at a similar level; however, the most frequent behaviours was a positive mental attitude.

In the literature on the subject, health behaviours include the conscious undertaking of health-oriented actions (various behaviours related to physical health, mental health, self-management of health, preventive examinations, safe behaviours in everyday life, common sense behaviour regarding diseases) and the elimination of all activities that pose a threat to life and health, both directly and in the long term (e.g., abstaining from tobacco, alcohol, recreational drugs, and psychoactive substances) [3]. One of the most important health behaviours is vaccination, which is the most effective preventive method for combating diseases.

A survey of a representative sample of 990 adults in Poland showed that 79% of respondents considered vaccinations the most effective way to protect children from serious diseases.

The vast majority of the surveyed parents (96.3%) declared that they vaccinated their children. The aforementioned survey of a representative random sample of 990 adults in Poland showed that 79% of respondents thought that vaccinating children causes more good than harm [22].

The present study showed that parents’ health behaviours were not statistically correlated their beliefs regarding the vaccination system, the quality of the vaccines used in Poland, the general obligation to gain immunity through "sickness," the need to vaccinate against all diseases and the acceptance of unvaccinated children in nurseries and kindergartens.

Some vaccinations are paid for by parents in Poland; in other countries, they are financed by the state or health insurers. Regarding the financial responsibility of the health care system, changes to the current vaccination programme have introduced a gradual shift from paid to unpaid vaccinations in Poland[12].

Almost three-quarters of adult Poles (73%) in a sample of 990 adult Polish residents reported that at least a some vaccinations should be obligatory, while 23% advocated that all vaccinations should be voluntary [12].

At present, many parents forego vaccinations. Negative opinions that undermine the effectiveness and safety of preventive vaccinations as a form of infection prevention are widely disseminated [26]. There are so-called anti-vaccine movements that aim to reduce mass vaccination. On online portals and forums, there is information regarding the harmfulness of preventive vaccinations, complications arising from vaccinations, and the impact of mercury on the emergence of autism, autoimmune diseases, or weakening of the body's resistance. Anti-vaccine content is also spread among those who use homeopathic and natural medicine [26]. A negative example of the dissemination of false information regarding vaccinations was the investigation by Wakefield, who put forward the concept of a relationship between the MMR vaccination and autism [27].

The elimination of measles in Europe is an urgent public health goal, yet despite the efforts of its member states, vaccination gaps and outbreaks occur. In a recent study from Germany, the authors found that 7.1% of children did not provide a vaccination certificate [30]. Furthermore, they concluded that the coverage for at least one measles vaccination was higher in the studied county than in most South German counties and higher than the European average.

In the present study, parents who believed that vaccines can cause autism showed a significantly higher level of prophylactic behaviour. Statistically, there were significant differences in health behaviour levels related to views on the toxicity of vaccines, mainly in terms of proper eating habits and a positive mental attitude.

In summary, it is worth re-emphasizing that the family, as the most important, most basic social group on which society is based, should provide future generations with educational development, including vaccinations, based on cooperation with health care units and other educational units.

Parents who believed in the toxicity of vaccines were more concerned about proper nutrition, had a more positive mental attitude, and had a higher level of preventive behaviours and health practices. Parents who did not vaccinate their children with combined vaccines had lower levels of normal eating habits, and those who vaccinated their children had a higher level of health behaviours, especially in the area of health practices.

Ethics approval and consent to participate
The study was approved by the bioethics committee of the Medical University of Bialystok, Poland R-I-002/196/2015 and the Directorate of Pro Medica Family Medicine Center in Bialystok, Poland. The informed consent obtained from study participants was written.

Consent for publication

Not applicable.

Availability of data and materials

The data analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

None

Authors' contributions

JK, EKK, KK, PK, made significant contributions to the conception and design of the study; MC AG, JL ,CŁ, KK, HD contributed to acquisition of data and initial analysis; AB, KKF and JR contributed to drafting of the manuscript. WK corrected the manuscript. All authors contributed to the interpretation of the data and revision of the manuscript. All authors approved the manuscript for publication.

Acknowledgements

We would like to thank Marek Sobolewski from the Quantitative Methods Department in Economics of the Faculty of Management and Marketing at the Rzeszów University of Technology, Poland for statistical analysis.

IHB: Inventory of Health Behavior

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Table 1. Health behaviours assessed using the IHB scale

IHB			Me	s	c₂₅		c₇₅	min	max
proper eating habits		3.4	3.5	0.7	3.0		3.8	1.5	5.0
preventive behaviours		3.5	3.5	0.7	3.0		4.0	1.5	5.0
positive mental attitude		3.6	3.7	0.6	3.2		4.0	1.5	5.0
health practices		3.2	3.2	0.6	2.8		3.7	1.3	4.7
IHB		82.1	82	12.3	74		91	47	111

Level of health behaviours	Number					%
low	99					33.0%
average	127					42.3%
high	74					24.7%

Table 2. Selected opinions of parents depending on their preferred health behaviours, part I.

	proper eating habits		preventive behaviour		positive mental attitude		health practices
		s		s		s		s
It is better to develop resistance by being infected than by vaccination
yes	3.47	0.64	3.57	0.67	3.78	0.61	3.45	0.61
no	3.42	0.64	3.54	0.66	3.58	0.60	3.20	0.61
hard to say	3.33	0.75	3.37	0.77	3.52	0.67	3.15	0.63
p	0.5632		0.2366		0.2531		0.1096
You should be vaccinated against all diseases
yes	3.38	0.69	3.50	0.66	3.57	0.64	3.10	0.61
no	3.42	0.69	3.45	0.69	3.58	0.60	3.29	0.58
hard to say	3.40	0.63	3.56	0.70	3.58	0.62	3.21	0.64
p	0.9595		0.2819		0.8752		0.1326
The current vaccination programme takes into account the situation in Poland
yes	3.40	0.67	3.50	0.75	3.55	0.66	3.19	0.64
no	3.49	0.61	3.59	0.61	3.58	0.49	3.18	0.58
hard to say	3.36	0.68	3.46	0.59	3.62	0.59	3.24	0.59
p	0.7630		0.6118		0.8036		0.7126
The vaccines used in Poland are safe
yes	3.40	0.64	3.52	0.71	3.58	0.62	3.19	0.63
no	3.60	0.67	3.58	0.56	3.71	0.56	3.00	0.59
hard to say	3.37	0.72	3.46	0.66	3.56	0.63	3.27	0.58
p	0.8341		0.7924		0.8125		0.3811

- Mean, s -Standard deviation

Table 3. Selected opinions of parents according to their preferred health behaviours. part II.

	proper eating habits				preventive behaviour				positive mental attitude					health practices
				s			s				s					s
Vaccines contain toxic ingredients
yes	3.67			0.66	3.67		0.55		3.80		0.52			3.36		0.61
no	3.40			0.68	3.49		0.73		3.61		0.64			3.22		0.65
hard to say	3.32			0.64	3.46		0.68		3.49		0.61			3.16		0.58
p	0.0381*				0.3287				0.0223*					0.1416
Vaccines cause developmental disorders and autism
yes	3.63			0.56	3.80		0.61		3.90		0.64			3.42		0.62
no	3.39			0.71	3.41		0.73		3.57		0.65			3.18		0.63
hard to say	3.37			0.63	3.54		0.64		3.54		0.57			3.20		0.59
p	0.2963				0.0375*				0.0773					0.2425
Vaccinations should be mandatory
yes		3.43	0.63			3.50		0.71		3.55		0.63	3.20		0.63
no		3.32	0.68			3.53		0.66		3.71		0.58	3.27		0.56
hard to say		3.33	0.82			3.37		0.58		3.38		0.62	3.08		0.66
only some		3.62	0.77			3.67		0.51		3.60		0.44	3.21		0.37
p		0.5949				0.5182				0.1777			0.8082
Children who are not vaccinated should not be admitted to kindergartens and crèches
yes	3.40			0.64	3.48		0.70		3.52		0.67			3.16		0.68
no	3.43			0.68	3.62		0.63		3.60		0.57			3.21		0.63
hard to say	3.37			0.69	3.42		0.71		3.63		0.59			3.27		0.51
p	0.8455				0.3155				0.5410					0.5826
I have doubts about vaccinating my child
yes	3.40			0.77	3.52		0.65		3.63		0.55			3.28		0.58
no	3.40			0.61	3.55		0.66		3.62		0.62			3.19		0.61
hard to say	3.38			0.68	3.26		0.82		3.30		0.67			3.15		0.70
p	0.9613				0.0823				0.0156*					0.4125

- Mean, s -Standard deviation

Table 4. Preference for child vaccination according to parents’ preferred health behaviours

	proper eating habits		preventive behaviour		positive mental attitude		health practices
		s		s		s		s
Has your child been vaccinated with high-priority vaccines?
yes	3.47	0.60	3.57	0.64	3.63	0.59	3.28	0.61
no	3.29	0.71	3.42	0.73	3.52	0.66	3.12	0.62
I do not remember	3.58	0.88	3.43	0.85	3.50	0.48	3.13	0.54
p	0.0584		0.2043		0.1620		0.0245*
Has your child had the recommended vaccinations?
		s		s		s		s
yes	3.47	0.65	3.59	0.69	3.62	0.67	3.28	0.66
no	3.31	0.62	3.40	0.68	3.56	0.56	3.12	0.57
I do not remember .	3.38	0.95	3.39	0.63	3.36	0.52	3.14	0.48
p	0.1009		0.0783		0.0868		0.0380*

- Mean, s -Standard deviation

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The impact of parents' health behaviours on their preferences regarding vaccinations

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