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Table 3 Supposed Causes and Potential Solutions of Vaccine refusals by regions

From: Unvaccinated children as community parasites in National Qualitative Study from Turkey

Regions Supposed reasons for vaccine refusal Potential Solutions
Istanbul
  Vaccine additives (pig blood and gelatin, monkey blood etc.)
Overload the immune system
Adverse reaction after previous vaccinations
Vaccines do not work
Religious factors; specific religious lifestyle
Distrust of foreign pharmaceutical companies
Anti-vaccine groups in social media
Initiatives to solve anti-vaccine politics of the sect or community leaders
Imposing sanctions on non-vaccination families (financial penalties, inability to benefit from health discounts, premium punishment, inability to use family medicine system, etc.)
Prevention of anti-vaxx broadcasting through social media channels and media organs
Preparation of pro-vaccination publications approved by the MoH, explaining the contents
Training children for vaccine advocacy
Creation of common working areas with the Presidency of Religious Affairs
Requirement for being fully vaccinated form at the school enrollment of children
West Marmara
  Vaccine additives (thimerosal and aluminum)
Possible adverse reaction after previous vaccinations
HCWs’ negative information about vaccination
Anti-vaccine publications in social media and newspapers
Prevention of anti-vaccine publications in the media
Making public information spots
Increasing pro-vaccination campaigns and broadcast publications in social media channels
East Marmara
  Possible serious acute and long-term adverse reactions
Specific religious lifestyle (sect); vaccine additives is harmful, forbidden by religion
Distrust of foreign pharmaceutical companies
Distrust of government health authorities
Anti-vaccine groups in social media
Preparing a strategy for the leaders of the congregation/cult structures, especially in the region
Establishment of vaccination centers to vaccinate and follow adverse events
Preparation of short films and public spots containing subliminal messages
Development of an action plan with the Ministry of Education for school vaccination
West Black Sea
  Harmful vaccine additives
May make the child sick (autism, SSPE and cancer)
Parental right to choose whether or not to immunize their child Specific religious lifestyle and beliefs about vaccine and additives
Anti-vaccine groups in social media
Problematic health literacy
Anti-vaccine publications in social media and newspapers
Informing the public about the vaccination and vaccine content by written and visual publications
Preventing non-scientific publications
Provision of legal regulations (inability to benefit from payments for Social Security Institution, no coverage of health expenses, increasing premium payments)
Raising awareness of mothers about vaccines; Use of message systems such as SMS, MMS and social media tools such as twitter, instagram, facebook
Adding a training program on the management of vaccine refusal to the curricula of HCWs
To ensure the participation of the district imams in persuasion visits
East Black Sea
  Vaccine additives (pig blood and gelatine)
Belief that vaccine changes genetic code
Doubting the need for some vaccines
Anti-vaccination attitudes of some religions
Negative attitudes of obstetricians about vaccination
Anti-vaccine publications in social media and newspapers
Bringing legal obligations to families who do not allow their children to be vaccinated
Northeast Anatolia
  May make the child sick (autism, SSPE and cancer)
Serious acute adverse reactions
Religious beliefs about vaccine additives
Lack of information among some health workers
Problems in the structure of the national health system
Distrust of HCWs
Distrust of foreign pharmaceutical companies
Anti-vaccine publications in social media and newspapers
Collaboration with the Presidency of Religious Affairs in solving vaccination problems
Ensuring the employment of health personnel who know the region and know their problems, reducing short-term appointments
West Anatolia
  Anti-vaccine opinions of sect leader: Vaccine additives are not appropriate to religion. Believing that vaccine changes genetic code and causes infertility
Parental right to choose whether or not to immunize their child
Potential for long-term adverse events
Belief that vaccines are unnecessary
Lack of required information on vaccine efficacy and ingredients among HCWs
Negative attitudes of obstetricians about vaccination
Distrust of HCWs or government health authorities
Distrust of foreign pharmaceutical companies
Anti-vaccine publications in social media
Providing counseling services for cases with vaccine adverse events and vaccine hesitancy and rejection
Establishment of operational committees to assess families who refuse vaccination and to develop strategies to ensure persuasion,
Providing postgraduate training to ensure consensus among physicians,
Health personnel should be fully informed about the vaccines they apply and should use standard informative brochures about the benefits of the vaccine,
Providing positive publications about vaccines in the national vaccination schedule on the media, using public spots,
Labelling vaccine boxes to indicate that the vaccine has been controlled by MoH and is halal.
Central Anatolia
  May make the child sick (autism, SSPE and cancer)
Serious acute adverse reactions
Belief that vaccine changes genetic code or causes infertility because of vaccine additives
Religious beliefs about immunization
Misinformation about vaccine by health workers
Distrust of foreign pharmaceutical companies
Health personnel should be fully informed about the vaccines they apply,
Public spots
Central East Anatolia
  Belief that vaccine changes genetic code or causes infertility
Vaccine additives
Serious acute adverse reactions
May make the child sick (autism, SSPE and cancer)
Not all vaccines are necessary
Parental right to choose whether or not to immunize their child
Specific religious life (sect) and religious opinions
Some HCWs’ inadequate knowledge about vaccine
Distrust of health workers or government health authorities
Distrust of foreign pharmaceutical companies
Anti-vaccine publications in social media
Ensuring that all HCWs are properly informed about the vaccines and their contents,
Revision of the curricula of pre-graduate education of health personnel,
Use of correct communication techniques in the community (some rejections can be prevented through giving “fatwa” in the region)
Giving vaccine information during pregnancy follow-up
Information via mobile phones
More attention should be paid to the application of cold chains to the area
Transition to oral vaccines instead of parenteral vaccines
Accelerating the production of domestic vaccines
Explaining that the decrease in infant mortality rates in the region is related to vaccination
Southeast Anatolia
  May make the child sick (autism, SSPE and cancer)
Belief that vaccine changes genetic code or causes infertility
Serious acute adverse reactions
Vaccine additives
Not believing that vaccine-preventable diseases can be serious.
Disease is more “natural” than vaccine
Specific religious life, religious beliefs; sin
Some HCWs’ misinformation about vaccine
Parental right to choose whether or not to immunize their child
Distrust of foreign pharmaceutical companies
Adding vaccine application to the positive performance criteria of family physicians
Publishing the scientific information to counteract false information
Correct information about the causes of SSPE cases in the region
Establishing vaccine information channel between obstetricians and family health workers.
Development of legal measures against non-vaccination families; e.g., withdrawal of health insurance cover, penal arrangements to be made in premium payments, direct fines, interruption of financial support of individuals receiving conditional cash transfers,
Mediterranean
  Belief that vaccine changes genetic code or causes infertility
Serious acute adverse reactions
Vaccines do not work
Vaccine-preventable diseases have disappeared
Anti-vaccine publications in social media
Preparing cards, brochures, magazines and books about the vaccines and their contents for public use
Aegean
  Belief that vaccine changes genetic code or causes infertility
Vaccine additives considered not appropriate to religion
Specific religious life (sect)
Some HCWs’ misinformation about vaccines
Distrust to health workers or government health authorities
Anti-vaccine publications in social media
Working with sociologists and social workers to determine a solution within the framework of regional features
Preparing cards, brochures, magazines and books about the vaccines and their contents for public use
Blocking access to anti-vaccine websites
Legal regulations