Vaccine Hesitancy Prevalence and Correlates in Riyadh, Saudi Arabia

Carried out in the context of the rise of vaccine-preventable diseases (VPDs) in both developed and developing countries, this study sought to evaluate the magnitude and level of vaccine hesitancy (VH) amongst parents in Riyadh, Saudi Arabia. It also examines the effects of social, economic, and educational factors on VH and offers communication-centred recommendations for preventing the spread of VH.

The researchers observe that vaccine delay seems to be the main reason for under-vaccination. The latter can have dire consequences; a study out of the United States (US) found that a 5% drop in measles, mumps, and rubella (MMR) vaccine coverage would triple the number of measles cases in children nationally every year. "These results support an urgent need to address vaccine hesitancy in policy dialogues at the state and national level with consideration of removing personal belief exemptions of childhood vaccination."

As the authors explain, 4 main sociocultural changes have contributed to VH: (i) low level of trust in large corporations that manufacture vaccines; (ii) growing public interest in natural and alternative types of medicine; (iii) change in the role of physicians (parents no longer want to be told what to do for their children, but, rather, want a shared decision-making process; (iv) paediatricians are increasingly under pressure to see more patients in less time and find themselves confronted with parents that find misinformation on the internet. Further, they find it more difficult to communicate accurate information to parents and address their concerns.

Parents' confidence in the safety of and need for vaccination is described in the paper as a spectrum ranging from: unquestioning acceptance, cautious acceptance; hesitance; delaying or selectively vaccinating; to those who decline all vaccines. Parents often move from one position on this spectrum to another, and it is the hesitant parents who are most likely to change their positions. Among the studies cited here is one that found that social networks exerted the strongest influence in the decision to not vaccinate. This means that non-vaccination is a racial and cultural trend, reinforced through the shared values, believes, norms, and expectations common to one's social network.

A sample of 238 parents taking their children to the paediatric outpatient clinic at Al-Takhassusi Hospital, HMG, in Riyadh between June 2017 and September 2017 for reasons other than vaccination were evaluated for this study. Using a standard questionnaire, parents were asked a number of questions to evaluate their vaccine-related knowledge, attitudes, and behaviour.

Key findings:

• 47 parents (19.8%) strongly agree, and 152 parents (64%) agree, that vaccines are essential for the health of their children to protect them from serious untreatable VPDs. 3 parents (1.2%) disagree and think that VPDs are transient and are not serious. 36 parents (15%) were neutral or did not know.
• Regarding vaccine safety, 21 parents (9%) thought vaccines could be harmful to child health. 16 parents (6.5%) think that vaccine could damage the brain. 170 parents (71%) consider vaccines entirely safe. 30 parents (13%) felt neutral about that.
• With regard to the Ministry of Health (MOH) vaccine schedule, 16 parents (7%) found it overloading. 39 parents (16%) felt neutral or selected "do not know". 183 parents (77%) were satisfied with the vaccination schedule.
• Some form of VH was found in 15% of the sample. 81 parents (34%) confirmed that at least one of their children had considerable delay in vaccination for more than one month. 60 parents (25%) attributed that to unavailability of vaccines. 15 parents (6.5%) delayed vaccines due to child's sickness or time constraints. 6 parents (2.5%) delayed vaccines because they believe they are not important (so, a minority intentionally delayed or dropped vaccination).
• Risk factors for VH were: middle age group 30-40 years (odds ratio (OR) = 5.41; 95% confidence interval (CI): 4.55-6.26), female gender (OR = 2.41; 95% CI: 1.02-3.27), high level of education (OR = 31.11; 95% CI: 20.62-41.11), living in the northern affluent geographical areas (OR = 7.6; 95% CI: 2.64-12.13), and using social media as the main source of information (OR = 30.6, 95% CI: 24.6-34.3).

The researchers reflect: "Some common factors seem shared between members of all the hesitant groups. Fortunately, the vast majority still give vaccines to their children in spite of their misinformation background or their hidden concerns. However, it is those hesitant parents who stand in-between and need our future approach and help to protect them from the anti-vaccine movements. Health authorities and academic institutions must work together to know characters of these groups, define them, and put the suitable procedures to explore their concerns and correct their misinformation. Ignorance of these groups which seems growing significantly worldwide may push them to the delay/drop group..."

Thus, preventive interventions for parents of the hesitant groups seem necessary to address their concerns and correct their misinformation. As indicated here, these interventions should be tailored mainly for mothers and grandmothers of the middle age group, living in the northern wealthier neighbourhoods of Riyadh and with high level of education. It seems that young parents still consider vaccines ordinary and accepted, but - in the context of strong family relationships - one misinformed, trusted grandmother may change the attitude of her related younger parents.

Another suggestion is to offer all young parents, with each delivery, clear and frank education before discharge about the real morbidity and mortality of VPDs. "For them it is something from the past. They need to feel the difference between the natural disease history of complications and the luxury of vaccine era. Vaccination is a national health necessity not a personal decision. Once we accept to live within a given society we must harness our behavior for the best interest of all."

Other recommendations offered here include: "Social media and internet pages should be screened by authorities and all harmful websites should be strictly ban[ne]d. It seems that specific pages should be established on the website of every hospital and every small medical center or even a small pediatric or family private or public clinic. [T]hese pages should be attractive with simple medical vocabulary. All the rumors about vaccines should be argued and justified very clearly....Possibility of comments, feedback, and communication also should be offered and directed by trained professionals."

In conclusion, although this study discloses that the national vaccination target of 95% to achieve herd immunity has been achieved in Riyadh, the researchers suggest that similar research studies in other parts of the city and also other cities are necessary. Such essential national health screening evaluations should be repeated on a regular basis to address harmful changes in parents' attitude spectrum early.