E-Health Literacy and the Vaccination Dilemma: An Israeli Perspective

Parents' hesitancy to vaccinate their children is becoming more prevalent in Israel. The aim of this research is to examine whether there is a relationship between the increase in parents' level of involvement in the decision to vaccinate their children, and the increase in searching for and filtering information from online electronic sources. It focuses on parents' perceived level of online literacy (e-health), their level of electronic information sources use and types of information sources, and their actual level of knowledge on the subject of vaccination.

The paper begins by providing theoretical background, starting from the history of individual or organised resistance to vaccination, which in more recent times can be linked to the 1998 publication of a paper in The Lancet - since then retracted - in which Andrew Wakefield pointed to a causal connection between the triple vaccine against measles, mumps, and rubella (MMR) and autism in children and babies. Unlike resistance to vaccination in the 18th century, which was based on religious beliefs, the present-day phenomenon of vaccination refusal is associated with a rational decision based on a thorough process of information research.

The current research is based on the health belief model, and the paper lays out characteristics of the model applied to vaccination refusal, looking at: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. Also explored here are previous studies on the internet as a tool for seeking information on medical topics. The growing influence of the internet as an initial source of information on medical topics has given rise to the concept of e-health literacy. The Lily model is based on a combination of 6 different kinds of literacies, which can be divided into 2 types: analytic, which includes traditional literacy, media literacy, and information literacy, and the content type that includes computer literacy, scientific literacy, and health literacy.

"[D]ue to the growth in the number of vaccination refusers, the question arises as to whether those who are non-conformers and hesitant about vaccination make their decision after a sophisticated and comprehensive search. Do they search for information in medically reliable sites? Are they impressed by the ease of use of the site and its design? Are they influenced by videos and pictures presented or the quality of information it contains? Do they know how to distinguish between reliable and invalid information?"

The study took place in December 2014 and January 2015. In the first stage, the researchers asked Facebook groups and forums' managers for permission to disseminate questionnaires to their groups. After getting their consent, they sent questionnaires to 2 forums and to 10 Facebook groups. The researchers received 210 questionnaires from parents of children born from 2000 forward. The questionnaire was distributed to a convenience sample; therefore it does not represent the entire population of parents in Israel. The researchers surveyed 5 aspects to gather data: demographic characteristics, vaccination intentions, level of online information sources use, knowledge on the subject of vaccination, and perceived e-health literacy.

Of participants, 125 (59.5%) were hesitant, and 85 (40.4%) were non-hesitant. The non-hesitant parents were found to be older and the child's age higher in comparison with hesitant parents. Some other selected findings:

• Significant differences between hesitant and non-hesitant were found concerning delaying vaccination,  χ2=65.23, p <0.001, and concerning future vaccination,  χ2=96.33, p <0.001.
• Hesitant parents have a greater likelihood of refusing vaccination than non-hesitant parents; that is, most parents who hesitated over whether or not to vaccinate decided against it. This finding can be explained by the health belief model.
• Non-refuser parents have the greatest knowledge about vaccination, followed by hesitant parents; refuser parents have the least knowledge.
• The refuser parents have the highest level of perceived e-health literacy, followed by non-refuser parents, then by hesitant parents.
• The higher the perceived e-health literacy, the more people search for information in government sites and social network sites.
• Hesitant parents search more in alternative sites, forums, and social network sites than non-hesitant parents. Refuser parents search more than other parents in government sites, alternative sites, and forums.
• In order to examine if there is a change between parents' intentions before and after their information search concerning future vaccination, researchers conducted a chi square test that showed a significant difference between the two dates,  χ2=96.33, p < 0.001. Figure 2 in the paper shows that 92.9% of non-hesitant parents reported that after receiving the information, they intend to vaccinate their children. Among hesitant parents, 24.0% reported that after receiving the information, they intend to vaccinate their children, 49.6% decided not to vaccinate their children, and 26.4% continued hesitating.

In reflecting on the findings, the researchers note that hesitant parents had lower knowledge concerning vaccination than non-hesitant parents. They conclude that perhaps parents who searched for information on the internet did not get precise information, and non-hesitant parents got information from other, authorised medical resources.

Practically, they suggest that in order to increase parents' willingness to vaccinate their children and their e-health literacy, medical institutions should adopt the strategy used by the anti-vaccination movement, which draws on videos, pictures, and social network sites to convey its messages via different online channels. Medical institutions could use these channels to illustrate the dangers of non-vaccination in order to increase parents' e-health literacy. Moreover, mainstream medical institutions are advised to direct parents to recommended health sites, where they can retrieve reliable information, and thus reduce the likelihood they will search sites offered by the anti-vaccination movement or sites that present misleading, inaccurate information.

The researchers indicate that a future study could also use qualitative methods such as open questions or interviews to supplement the quantitative analysis, and thereby enrich the findings by adding other dimensions to the process. Moreover, a further study may use an internet site supporting vaccination, where the messages are conveyed via social network sites, videos, and pictures, and examine its effect on individuals' decisions to vaccinate.