Pro-vaccination Groups Expressing Hesitant Attitudes: A Cross-Sectional Study About the Difference Between Attitudes and Actual Behavior in Israel

"Pro-vaccination individuals may have hesitant attitudes regarding vaccines."

Vaccine hesitancy has become more prevalent in recent years and is considered a public health concern in Israel. However, there is broad debate around the definition of vaccine hesitancy, where some definitions are solely based on the actual behaviour of individuals (uptake), regardless of their attitudes, while other definitions take into account hesitant attitudes. In light of this debate and the fact that there are few empirical studies focusing on individuals who vaccinate according to the recommended schedule but still have concerns, this study examines  the gap between hesitant attitudes and actual behaviour in pro-vaccination groups in Israel.

An online survey was distributed in January 2020 to a panel of samples that represented the adult population in Israel; of the 558 participants, 451 were pro-vaccination, and 107 were hesitant. The first part of the questionnaire featured a filtering question that asked if the participant was a parent of a child in kindergarten (3-5 years old). If so, they were moved to the second part of the questionnaire, which collected demographic information and asked if they give their children all the vaccines according to the nationally stipulated vaccination schedule. The third part of the questionnaire was based on a validated scale on vaccine hesitancy, which was culturally adapted to the Israeli population. It included an index of seven 5-point Likert scale statements that asked the participants to indicate the degree to which they agree or disagree with each statement focused on the effectiveness and importance of routine vaccines.

First, the Chi-square test for independence was used to test the difference between sociodemographic characteristics and the rate of hesitant attitudes. All the sociodemographic characteristics were found nonsignificant for gender, age, religious affiliation, and education. In the second stage, a significant difference was found between the rate of hesitant attitudes and the rate of hesitation in actual vaccination, where 26% of the parents have hesitant attitudes, but only 19% hesitate in practice. In the third stage, McNemar's test for dependent proportions was used to test the difference between the rate of hesitant attitudes and the rate of hesitancy in practice by background characteristics. One finding: The higher the parents' education level, the smaller the difference between hesitant attitudes and vaccination uptake - perhaps because highly educated parents tend to make reasoned and informed decisions based on the literature they choose to read (health literacy).

Different interpretations can be offered to explain the gap between hesitant attitudes and behaviour; the researchers discuss two of them:

• Social norms: Since there is a very high percentage of childhood vaccine uptake in Israel (more than 90%), it is possible that parents who feel worries and concerns are persuaded to do so because vaccines are accepted in society. According to conformity theory, social groups often penalise individuals who deviate from accepted norms. As a result, individuals tend to suppress their individuality and conform to social norms to maintain their social acceptance. Health professionals and public policies tacitly motivate parents to vaccinate and conform to social norms. First, health professionals give parents information that is not only designed to advise but also to induce conformity; as reported here, the information may fail to include all the information about possible risks or side effects. In addition, the ongoing debate regarding required immunisation as a condition for children's admission into the educational system in Israel puts some parents under social pressure. This debate makes it difficult for parents to ask questions regarding vaccinations and to come to a reasonable decision on their own.
• Risk perception: It may be that parents choose to vaccinate their children despite their concerns because of their low risk perception of the adverse effects of vaccines and high risk perception of disease infection. Studies support the idea that lack of accounts of any injuries in children in parents' social circles contributes to their low risk perception. Furthermore, the phenomenon called "optimism bias" suggests that when it comes to predicting what will happen to us in the future, we overestimate the likelihood of positive events and underestimate the likelihood of negative events. In the context of vaccines, parents tend to be more optimistic regarding vaccinating their children and underestimate the likelihood of vaccines' potentially serious adverse effects.

Based on the findings, the researchers recommend that health authorities and policymakers address the fears and concerns of all groups, including those who are pro-vaccination, taking into consideration the difference between hesitant attitudes and hesitancy in practice, based on sociodemographic characteristics (gender, age, marital status, education, and religious affiliation).