The main feature of the Polish parents in the pilot cohort was an increase in their return rate of the consent forms by 20.7%. This was formed of 20 pupils’ parents who chose to consent this year, while over twice as many (41) chose to refuse the vaccination. This suggests that nearly two-thirds of pupils’ parents, who previously did not return consent forms in 2017, could be described as ‘passive refusers’. That is, they knew an unreturned form would mean that their child would not be immunised.
Evidence from the control school cohort shows there was a much smaller increase in the return rate of the consent forms, suggesting the intervention had some effect. Polish parents refusing the influenza vaccination in the control school cohort increased by 3.2%, while the number of parents consenting increased by 0.5% (only one pupil). This, again, may be due to a significant increase in the number of returned consent forms, suggesting that many of the non-returning parents in previous years may have also been ‘passive refusers’.
This pamphlet study is the first intervention used to increase the uptake of the influenza vaccination in the Polish community nationally in Scotland. Brief written education interventions, such as pamphlets, are the most tested interventions in literature reviews, but were previously found to have little or no impact on vaccine hesitancy [19, 20]. Previous studies on influenza pamphlets interventions found providing education intervention in the waiting room before a paediatric provider visit may help increase child influenza vaccine receipt  as well as higher uptake in maternal influenza vaccination uptake in pregnancy  however pamphlet intervention was found ineffective in increase uptake a minority group, due to lack of personalisation and authority association in a 2018 study with Aboriginal children . The decision-making process of consenting to vaccination is complex, as evidenced by the feedback from the questionnaire.
The majority of respondents (58.6%) remembered reading the new NHS Health Scotland Polish influenza pamphlet, and of those who had read the pamphlet, 82.7% stated they had read all of it and a majority of those found “all” or “everything” in the pamphlet useful. A few parents left comments expressing the desire for more information about ingredients found in the influenza vaccine. This concern was also shared with the researcher in a previous qualitative study with Polish mothers . The updated pamphlet provided a direct URL link to the patient information leaflet, which lists all the ingredients of the intranasal vaccination. This suggests that the respondents had not read the pamphlet carefully or did not follow up online to check. In the next version of the pamphlet, this can be improved and made easier to find.
From the questionnaire, it was revealed that parents selected “previous experience” of the vaccination 53% of the time as the most important factor in their decision-making process when deciding whether to give consent for the influenza vaccination, and this did not differ significantly by consent form status. Polish migrants if they have arrived recently in Scotland will be unfamiliar with a school-led influenza programme, as one does not exist in Poland. Influenza vaccination is not a mandatory vaccination in Poland, and costs fall on the patient. Overall, it is not a popular vaccine and uptake is very low with the influenza vaccination uptake rate remaining at a 3% threshold nationally in the past 10 years . The influenza vaccination uptake rate differs widely in Poland and depends much on the age and risk group. In patients with chronic diseases, as well as the elderly, immunization coverage is higher than in the general population; however, this still remains well below the recommended level, which is the 75% uptake in key risk groups [13, 25, 26]. The attitude toward influenza infection and vaccination is different in Poland; it is not regarded as an important vaccination and there is a lack of awareness of its need - in a national survey in Poland [24, 25] important gaps in the knowledge on influenza vaccination were found in the general Polish population.
Although healthcare staff, doctors in particular, are traditionally seen as being important in shaping health behaviour, they ranked low in this sample, especially among the refusers - only 6.2% of refusing parents chose medical staff as a key source of information about vaccines. The healthcare staff role must be enhanced to increase the influenza vaccination coverage among Polish children in Scotland, and according to the results, respondents provide a potential answer, as their top source of information about vaccinations was related to social media.
Considering that the majority of respondents have lived in Scotland for several years, the fact that they consult practitioners in Poland as much as in the UK is an indication that they continue to live in a community heavily influenced by Polish norms and values. In a 2016 cross-sectional survey of parents in Poland, it was found that medical doctors often provide the basic source of information about vaccination to parents, however, 16.9% of respondents declared that information received from physicians regarding vaccinations was either incomplete or unconvincing . This Polish literature confirmed that participants in Poland were less likely to seek information about vaccinations from medical professionals, and participants who used less accurate sources, were more likely to avoid vaccination.
Overall, respondents’ top six sources of information about vaccinations were related to social contact, internet-based media and previous experience. Polish language sources were more prominent than English ones. In our study, the consenting parents had the NHS Polish influenza pamphlet as the second most selected source of information, previous experience was rated highest. Social media, where users often share anti-vaccination material [28,29,30], was significantly more likely to be cited as an influence by refusing parents than by consenting ones.
While the internet is used by health promoting organisations for positive and informative messages, it is also a vehicle for unmoderated anti-vaccination sentiment and misinformation. The UK-focused 2019 Royal Society for Public Health report  found that 41% of parents surveyed had been exposed to negative messages about vaccination on social media, rising to 50% of parents of children under five. The report discusses the risk that repetition of incorrect information is often mistaken for accuracy, citing an American study  that revealed that even when participants were provided with prior knowledge, they could succumb to the effects of ‘illusory truth’.
Even if just a small percentage of the population is opposed to vaccinations, social media facilitates anti-vaccination connections and organisation  and allows “echo-chambers” which exaggerate the group to appear larger than reality. Various social media platforms provide an online space for unregulated anti-vaccination and counter-factual information, such as lengthy lectures on YouTube by Polish doctors and academics [34, 35] who are very sceptical about vaccination. As a result of the findings of this study, and recognizing the need for accurate, evidence-based information about vaccination on social media , NHS Health Scotland created an immunisation focused Twitter account in March 2019. Through this account, they have shared Polish-language Tweets and infographics to promote the influenza vaccine and have engaged with the Twitter accounts of several Polish community groups in Scotland, in an attempt to further reach the Polish community with accurate information about immunisations. There is also a need to increase the presence of healthcare workers on social media . Another approach to explore would be the use of talking-head videos with Polish healthcare workers in Scotland promoting the influenza vaccine, to be shared not only on NHS Twitter accounts but through the social media channels of schools and Polish community groups in Scotland.
There are efforts being made by social media platforms such as YouTube and Facebook to change their policies to reduce the amount of misinformation on their sites [37, 38]. Pinterest recently changed their search engine to only provide results from major health organisations for 200 terms related to vaccines, and bar any advertisements, recommendations and commentary on those pages . Efforts need to continue to bring accurate information to the top of vaccine-related searches and remove false information that can harm people , but the challenges around curating content online are complex, as social media websites have the challenge of verifying the veracity of each user’s post, and restricting users’ freedom of speech.
Ethnicity was determined for 94% of participants in the study by using multiple methods and uptake was calculated using clinical records rather than self-reporting. The NHS data systems and recording of ethnicity data and education data are robust and we believe we have attributed ethnicity accurately. We also utilised name searching of consent forms by a Polish-native researcher (KB), which is an option not available in all locations. Polish pupils, not registered as Polish and without a Polish last name, may have been categorised in the Unknown section. A name recognition software such as Onolytics can be used as an alternative, which has been validated in several studies .
Study participants were limited to nine schools in one area of Scotland. While we have no reason to believe that these children and parents/carers from Edinburgh are atypical of Polish migrants in general, studies in other areas would be useful to ascertain whether our findings apply elsewhere. Larger studies would allow disaggregation of our other identified ethnicities, such as other European, Asian or minority groups, which could give useful information to vaccination programmes. Following vaccination behaviour by ethnicity over a longer period would be of value in evaluation.
In future questionnaire research, it would be interesting to pose a question about preference for mode of administration in the questionnaire, to find out if the nasal component is off-putting to Polish parents, as in Poland, the influenza vaccination is not administered nasally.
There was a 4.5% increase in the number of vaccinated children in the Polish cohort following the distribution of the tailored Polish pamphlet. While this result was not statistically significant given the sample size in the study, it suggests there is a potential for the pamphlet to increase the number of vaccinations among Polish pupils with a larger sample size.
The response rate to the questionnaire was moderate, with 128 out of 365 (37.3%) questionnaires returned. This is a limitation which might have introduced bias, however there was an even response from both the parents who consented (41.7%) and those who refused (39.4%) the nasal influenza vaccination for their child. In future research, it would be of interest to delve into respondents’ previous experiences, whether it was a previous adverse event with a vaccine or past behaviour dictating current behaviour. This would aid in preparing healthcare providers to discuss with patients about these previous experiences. Moreover, as Social Media, and both English and Polish websites were listed as sources of information, it would be of use to have respondents specify what web pages and social media outlets they turn to when making vaccination decisions.
The increase in consent form return rate was not as marked in the control schools as it was in the pilot schools - this may be due to the schools’ differing adherence to the influenza education package. The increase in consent form return rate could have been influenced by proactive narrative from a nurse in the Community Vaccination Team (CVT), who led the school influenza vaccination programme at the three pilot schools. The nurse ensured schools followed the promotional campaign and sent timely emails and text message reminders to parents to return consent forms, however we have no knowledge of the level of nurse or online promotion activity in the control schools. As such, the confounding factor of the difference in nurse enthusiasm cannot be accounted for, leading to uncertainty about the effectiveness of the pamphlet intervention. The study could be repeated with a controlled level of nurse involvement.