...advocacy campaigns and social mobilization to support immunization. The findings from this study...

Research Knowledge, Attitudes and Practices in Relation to Immunization of Children In Serbia

Publisher UNICEF Belgrade

For Publisher Michel Saint Lot, UNICEF Representative in Serbia

Design Agency CITLIK

Year of publication 2018

ISBN 978-86-80902-07-4

The research for UNICEF conducted by Ipsos Strategic Marketing

Contents Foreword 3

1. Executive Summary 5

I Research purpose 5

II Research objectives 5

III Research methodology 6

IV Main findings & conclusions 7

V Recommendations 12

2. Background and Rationale 15

2.1. Immunization in the Republic of Serbia 16

2.2. Rationale and Aims of the Research 21

3. How the research was conducted 23

3.1. Management and Quality Assurance 23

3.2. Literature review of previous research on vaccination coverage and public communication strategies 25

4. Overview of Methodology 49

4.1. Qualitative research with parents of children aged from 0 to 7 years 50

4.2. Qualitative research with health workers and key informants 52

4.3. Quantitative survey with parents/mothers of children aged from 0 to 7 years 53

4.4. Chronology of quantitative and qualitative design & project phases 58

5. Research Ethics 59

6. Research Findings 63

6.1. Report from in-depht interviews with health workers and key informants 63

6.2. The main measures used in the research 71

6.3. Report from the quantitative and qualitative research - general population 73

6.4. Report from the quantitative and qualitative research - Roma population 113

6.5. Analysis of determinants of future vaccination behaviour - general population 150

7. Conclusions 155

7.1. Institutional and legal framework related to vaccination 155

7.2. Knowledge, attitudes and practices of parents regarding the immunization of children-integration of qualitative and quantitative findings 158

8. Recommended measures for enhancing vaccination coverage in Serbia 167

8.1. Recommendations for communicating with parents (guidelines for tailoring vaccine-related interventions) 167

8.2. Institutional recommendations 175

References 176

Appendices 179

Knowledge, Attitudes and Practices in Relation to Immunisation of Children in Serbia 2

3Foreword

Foreword

Immunization saves millions of lives every year. Vaccines enable protec-tion of children from serious diseases and therefore play a central role in reducing mortality and preserving the health of children. Today, vaccines are protecting more children than ever before, but almost one in five in-fants in the world, more precisely 19.5 million children, does not receive even the most basic vaccines, making these children vulnerable to dan-gerous diseases. More than 1.5 million children die annually from vac-cine-preventable diseases.

Immunization is a proven, cost-effective strategy for public health that pro-tects both the individual and the entire community. At the same time, im-munization has become a victim of its own success, because many vac-cine-preventable diseases have become so rare that some people believe they have been eradicated forever, so they do not understand the benefits of immunization.

However, vaccine-preventable diseases still pose a threat around the world. In the WHO European Region, which comprises 53 member states with traditionally high immunization coverage, the recurrence of measles, rubella and whooping cough shows that these risks are real. The current immunization coverage rates in the WHO European Region are insufficient to ensure immunity and stop the spreading of vaccine-preventable diseas-es in the region. In previous years, the immunization coverage rates, es-pecially for some vaccines, have decrease in Serbia as well. For exam-ple, the coverage with MMR1 vaccine decreased from 93% (2013) to 81% (2016). There are numerous reasons for this phenomenon, but we know that some children are not vaccinated because their parents are insuffi-ciently informed about the need for immunization (e.g. in the hard-to-reach populations) or have misconceptions about the safety and effectiveness of vaccines (one of the causes is the public debate about the MMR vaccine).


The study “Knowledge, attitudes and practices related to immunization” was carried out in order to generate and document the evidence of the existing attitudes and practices in the field of immunization among care-givers/parents from the general population and those coming from vul-nerable groups (the poorest households, Roma communities), which will form the basis for the development of messages and materials for public advocacy campaigns and social mobilization to support immunization.

The findings from this study pointed to the behaviours and needs of parents in relation to immunization, but at the same time they also fo-cused on defining the institutional recommendations that should im-prove the implementation of the mandatory immunization programme in Serbia. The results of the study will be used by both UNICEF and WHO in their efforts to support the participants in the immunization process at the state level, primarily the health care system, in order to improve the access and support to parents and achieve higher immunization coverage.

For conducting the study, we owe special gratitude to all the experts and representatives of the stakeholders who participated in the inter-views, as well as to the parents who, by responding to the question-naire, shared with us their knowledge, attitudes and practice. We would also like to thank Ipsos Strategic Marketing and the experts Iris Zezelj, Jasna Milosevic Djordjevic, Dunja Anzelm and Dragoslav Popovic, who approached this study with professionalism and inspiration, trying to consider the complexity of the relationship between parents/guard-ians and immunization and to prioritize the most important areas in the field of communication in this area. On behalf of UNICEF, significant professional contribution and organizational support were provided by Aleksandra Jovic and Jelena Zajeganovic Jakovljevic from UNICEF in Serbia, and Svetlana Stefanet, Sergiu Tomsa and Eduard Bonet Porqueras from the UNICEF Regional Office for Europe and Central Asia in Geneva.

5Executive Summary

Executive Summary

I Research purposeThe vaccine stimulates the immune system to produce the antibodies that further protect the vaccinated person from a certain disease. If the majority of the population in a commu-nity is vaccinated against a disease, the whole community will be protected, including those who have not received the vaccine.

Despite the proven benefits of immunization, vaccine-preventable diseases (VPDs) contin-ue to pose a threat worldwide, evidenced by outbreaks of infectious diseases. Today, immu-nization seems to be the victim of its own success. In the past years, the level of immunized people dropped worldwide. Current immunization coverage rates in the WHO European Region are insufficient to ensure herd immunity and halt the spread of VPDs in the Region. In some countries with previously high coverage, rates have now fallen well below 95% of the WHO-recommended threshold.

Available data from the Institute of Public Health of Serbia register a significant decrease in coverage of Measles, Mumps and Rubella (MMR) vaccine in Serbia. However, even though the coverage is the lowest for the MMR vaccine, the coverage for almost all obliga-tory vaccines is decreasing and is the lowest in the ten-year monitoring period. This trend needs to be linked to caregivers’ knowledge and attitudes about vaccination, as the vacci-nation behaviour is related to attitudes. Some of the barriers to vaccination were described in international literature, but their true influence on population in Serbia has never been thoroughly researched.

Availability of such information would be a key pre-requisite for initiation of a dialogue be-tween the health system and its users - the wider community - on removing myths and distrust over the necessity and safety of the vaccination. A proactive approach to commu-nication can help alleviate the negative impact of rumours and misinformation on the im-plementation of immunization. The research findings will serve as the basis for the devel-opment of messages and materials for public advocacy campaign and social mobilization.

II Research objectivesHaving all this in mind, this research aimed to explore:

(a) the institutional barriers to desired vaccination coverage (e.g. pitfalls in the supply chain, in the inter-institutional communication etc…);

b) Serbian parents’ attitudes, knowledge and practices (experience with the health system)

1


regarding vaccination; potential socioeconomic, ideological (religious, for example) and psychological (lack of trust in health system, belief in medicine related conspiracy theories, widespread myths about vaccination) barriers to vaccination;

c) Serbian parents’ media consumption habits and their preferred content and ways of com-munication regarding vaccination.

Based on the all gathered data, this research should guide a detailed level of understand-ing as to what drives caregivers’ vaccination practices; explore the role that vaccination pro-viders play in influencing caregivers’ vaccination choices and actions, design evidence-in-formed responses to all findings to increase immunization rate.

III Research methodologyThe research entailed both qualitative and quantitative methods, developed drawing from an extensive literature review.

Desk research included a comprehensive analysis of the existing global and local documents, studies, reports. The aim of this part of the research was to provide a general wider context of the current situation in the world and Serbia concerning immunization and related knowledge, attitudes and practices. For the purpose of this phase, the team reviewed data, reports and research published and "grey" literature (Facebook communication, forums, blogs) on the topic of immunization.

In-depth interviews with 24 medical workers and key informants were conducted to provide the key stakeholders’ perception of immunization process in Serbia, especially in comparison to EU countries; to evaluate the legislative framework on immunization and success of its implementation; to provide information about vaccine availability and storage (to diagnose the demand- and supply-side barriers to vaccination); to identify strong and weak links in institutional communication and coordination; to provide opinion about the quality of communication between medical workers and parents/caregivers and general public; to define expectation of the trends in immunization coverage.

Focus groups with parents through qualitative research method searched for parents’ in-depth motivations for accepting/refusing vaccinations. The main goal was to explore the process of decision making. Focus groups also provided additional material for structuring the quantitative survey: concrete practices and perception of advantages and disadvantages of vaccination. A total 20 focus groups with parents of children aged 0-7 years old were conducted1 targeting parents who vaccinate their children as well as those who don’t vaccinate children, from the general population and population living in Roma settlements.

KAP survey with parents was implemented to identify knowledge about vaccination, pro and anti-vaccine attitudes and past and future vaccination behaviour on representative sample of Serbian parents (including the boosted sample for Roma population) with children aged 0-7. The research was defined to provide data about the main socio-demographic variables including children's age, number of children, gender, parents’ education level, employment status, SES, distribution across urban/rural settlements. The survey sample

1 This age range was targeted because majority of mandatory vaccinations and re-vaccinations are planned for by the age of seven; this is also the age of entering the school system in the Republic of Serbia, and a full vaccinal status should be prerequisite for a child to enroll (although this is not enforced in most of the cases, as will be addressed further in the text

7Executive Summary

included 824 households for general population (635 „face-to-face“ Computer Assisted Personal Interviewing-CAPI and 189 Computer Assisted Web Interviewing-CAWI) and additional (boosted) sample consisted of 213 "face-to-face“ CAPI interviews with Roma population in their settlements.

The research was designed in a way in which the results of previous stages informed the following ones.

IV Main findings & conclusions Majority of parents claim that they have taken their children to vaccination following the im-munisation calendar (92%); 4% hesitated but took them, and 3% refused some vaccines. Less than 1% of parents refused vaccination completely. As for future behaviour of parents regarding vaccination of children, the situation is not very encouraging: although majority of parents still have no dilemma and claim that they will surely adhere to the calendar (81%), quite many of them state that they will delay some, but probably do it (14%) and 5% will skip some vaccines; the number of absolute opponents of vaccination is still small (1%).

When these two parameters are compared, it is obvious that the situation is more unfavour-able regarding the future vaccination intentions than regarding the parents’ past behaviour. Although the number of parents who absolutely refuse vaccination is not rising, the num-ber of hesitant parents is (those who would postpone vaccination, or skip some vaccines).

If fears of this group of parents are not adequately addressed, they may become “radical-ized”, so it would be good to tailor future interventions to this target group. The following analysis presents their socio-demographic and psychological profile2.

Vaccine-related experiences with public health system. Most parents stated that they were informed about the next vaccination (86%), were informed about diseases which are prevented by the administered vaccine (76%), were informed about side effects (79%) and how to deal with them if they appear (82%). 42% of parents from general population stated that their child had a mild reaction to the vaccine, and only 3% stated that their child had a strong reaction. Some parents (17%) didn’t receive answer to their questions about vaccination and their percentage is higher among parents from Belgrade (25%). Vaccine shortage was reported by 14% of parents. No significant differences in vaccination experience emerged when respondents’ answers were broken down by age, education, region, employment and financial situation. About 17% were invited by phone or written notification from the health facility and it seems that this practice is more common in rural areas (22%). In rural areas parents experienced less waiting for vaccination in the health centre (16%) indicating that health centres in urban areas are more crowded (25%). Parents from Higher percentage of parents from Belgrade stated that they were left with unanswered questions after visiting the doctor (25%).

Hesitant parents are more likely than supporters to mention their negative experiences when communicating with paediatricians (they didn’t answer parents’ questions, they didn’t provide information about adverse effects or about managing them), to state that vaccines weren’t available or that they had to wait too long, as well as that adverse effects occurred.

2 Please note that information about vaccine supporters and vaccine-hesitant parents draws from both quantitative and qualitative data, whilst information about strong opponents of vaccination draws only from focus groups they were specifically recruited for (this cluster of parents was too small for reliable statistical analyses).


However, despite all registered differences, the results don’t suggest that the overall experi-ence was negative in either of the two groups. When they were asked to give a general as-sessment, they mainly described their experience as positive (96% of supporters and even 84% of hesitant parents).

Qualitative data complemented these conclusions. Supporters of vaccination had no expe-rience with reactions to vaccines, except for mild reactions such as fever or mild redness, and they were familiar with these potential effects because their paediatrician informed them about this. However, some parents state that vaccination is certainly traumatic and stressful for children. None of the interviewed parents mentioned serious complications af-ter receiving vaccines, although, quite expectedly, opponents of vaccination reacted more negatively to all.

Vaccination-related knowledge. Knowledge about the principles of vaccination is gener-ally very poor in all tested groups: more than 10% of parents did not answer correctly to a single question, while only 1% responded correctly to all questions. More than half of par-ents (52%) answered two or less than two questions accurately. Parents mainly knew what revaccination was and which diseases BCG vaccine prevented; one in five parents knew against which diseases MMR protects (despite it being the most stigmatized by the me-dia), and one in seven knew why against which diseases DTP vaccine protects. There was a weak correlation between personal assessment of knowledge and objective knowledge about the immunization process, indicating that parents tend to overestimate their actual knowledge. We detected no differences in knowledge between the groups of parents who support and don't support vaccination. Older and better-educated parents scored better on the test, while Roma parents knew a lot less than parents from the general population.

In focus groups, parents with the positive attitude towards vaccination considered them-selves averagely informed; at the same time, they believed that parents in Serbia were generally uninformed. Parents from Roma population perceive themselves as even less in-formed about these topics, while parents with extremely negative attitude considered them-selves better informed than the rest of the population. Majority of parents were not familiar with the symptoms, severity or potential complications of these diseases. For instance, op-ponents of vaccination typically thought all measles were harmless.

Assessment of the risk of (non)vaccination. The highest percentage of the general pop-ulation stated that vaccination is useful altogether (84%), and that vaccination should be mandatory (72%), although 40% stated that there should be consequences for parents who refuse to vaccinate children, 77% are worried that their child will get a disease if not vacci-nated. So, more parents agree with the benefits then with barriers of vaccination. However almost half of the general population (49%) agree (completely or somewhat) that they are worried about the side effects of the vaccines, 44% were worried that vaccines can trigger other diseases, 34% stated that they were worried about multiple vaccines in one take, 47% of parents were worried about the quality of the vaccines.

When assessment of vaccine-related risks was analysed by socio-demographic data, again the same pattern emerged: only education and region were somewhat significant in gener-al population. Less educated parents reported to be less worried about side effects of vac-cines (34%), other diseases that can be triggered by vaccination (28%), risks of multiple vaccines in one shot (21%) or too early age for vaccination (14%). Belgrade parents report-ed to be more worried about all those issues, in comparison to parents from Vojvodina, who seem to be less worried.

9Executive Summary

Quantitative research showed that the attitudes towards vaccination were generally positive both among supporters and hesitant parents. Parents from both groups believe that vac-cination is useful; supporters are somewhat more likely to share this opinion, as expected. While supporters of vaccination worry about vaccine-preventable diseases, but not about the safety of vaccines, hesitant parents worry about both. This is an important difference be-tween the hesitant parents and the opponents of vaccination, as the latter usually consider vaccine-preventable diseases "mild" or "diseases that strengthen immunity". Hesitant par-ents, however, detect risks on both sides and they seem to find it hard to "rank risks", or to estimate what is more dangerous for a child.

In qualitative portion of the research, parents with the positive attitude towards vaccination spontaneously mentioned numerous advantages of vaccination: prevention of epidemics, precaution, psychological stability, protection of the child and the whole society. Roma par-ents were less fluent about the advantages of vaccination, but they were generally aware of their role in disease prevention. Parents with positive attitude towards vaccination were aware of the negative propaganda against vaccination and they complained that health pro-fessionals did not confront it enough. Parents with extremely negative attitude saw no ben-efits in vaccination. Their main complaint was that vaccination was mandatory by Serbian law and that parents were not allowed to decide for their children as their main caretakers.

Myths and conspiracy theories about vaccines. Myths related to vaccination are not widely accepted among general population. However, it is worth noting that almost one third of parents believe that imported vaccines are of poor quality (32%) and that their quality is not properly controlled (33%). Similar share of parents believe that too many vaccines ham-pers children’s immunity (26%), that it would be better if children were older when vaccinat-ed (27%) and that medicine today can cure diseases addressed by vaccines more success-fully than side effects of immunization (30%). Only small percentage of parents agree that MMR causes autism (15%) and that vaccine preservatives are toxic (16%). Although radical differences in endorsing vaccine-related myths were not registered, once again they were less endorsed by lower educated parents and more endorsed by parents from Belgrade, and unemployed parents.

Myths about vaccination are not widely accepted either by supporters or by hesitant par-ents, but hesitant parents seem to trust them more. The most widely accepted are the myths about control of quality and the process (dynamics) of administering vaccines. The least ac-cepted myths are those that minimize the danger of vaccine-preventable diseases. Hesitant parents were more likely to believe in conspiracy theories than supporters of vaccination, and these differences are systemically registered on all points of the story that the authori-ties and pharmaceutical industry hide data about the dangers of vaccination. Results, how-ever, don’t suggest that hesitant parents accept such statements without reserve, but that they are indecisive, while supporters of vaccination reject them strongly.

Vaccine-related decision making; support for vaccination in the social environment. The majority of parents (90%) see health providers as the greatest supporters of immunization, but also state that their family (80%) and close friends (70%) support it. There is, howev-er, the perception that other parents support vaccination in smaller percentage (58%). Less than half of parents and only one third in Central Serbia recognized media as instance sup-porting immunization (46%) probably because of the anti-vaccination content that the public has been exposed to over the past years. Supporters of vaccination assess that all stake-holders in their surroundings support vaccination (especially family and close friends), while hesitant parents are more likely to perceive the surroundings as undecided.


In qualitative research, numerous parents (even strong vaccine supporters), reported some instances of doubt. Some mentioned consulting their paediatrician – while some paediatri-cians supported vaccination openly, the others took more neutral stance. They stated that parents have the right to decide whether they will vaccinate their children or not. In general, the decision about vaccination is perceived to be an individual one and consequences of non-vaccination for public health are not recognized. When parents (especially anti-vacci-nation parents) are presented with anecdotic examples of positive and negative experienc-es with vaccination, some regularities are detected in their thinking: a. they tend to interpret correlations causally, or to perceive events as causing one another (vaccine as a distinctive event is adequate for this type of interpretation), b. there is no time limit between events re-lated in this way (all unwanted effects that happen months after vaccination are attributed to vaccination) and c. they fail to perceive differences between mild and serious adverse ef-fects – they perceive both as serious risk of vaccination.

Trust in medical authorities and in science. The picture of public opinion when it comes to confidence in health authorities is rather encouraging: 82% of parents trust their paedi-atricians (89% of supporters, and 61% of hesitant) and official medicine (79%). More sup-porters (84%) trust official medicine comparing to hesitant (62%).Confidence in institutions connected with production (43%) and quality control of drugs (47%) is somewhat lower, particularly among hesitant parents (36% have confidence in national agency for Quality Control, and only 27% in pharmaceutical industry among hesitant parents).Both vaccine supporters and hesitant parents report they strongly trust science, although the hesitant group was more likely to suspect the motives of scientists and scientific method as the only reliable way to find out the truth about the world.

Media consumption. There are no striking demographic differences when it comes to me-dia use for health-related issues. Higher educated parents from general population use of-ficial Internet sites and forums/blogs more. Majority of parents (67%) receives information about vaccination from health providers. About 22% use TV, Internet sites (26%) or social media (19%) to inform themselves about vaccination. About 12% use printed media and forums and blogs (18%) while only 3% use radio. Parents with low education level use all media to a lower extent while parents with high education use Internet and forums/blogs in a significantly larger percentage. Both hesitant and supportive parents mainly get informed about vaccination by medical workers, and in their immediate surroundings (family mem-bers and other parents). Parents who are hesitant regarding vaccination are more likely to use all types of media than supporters of vaccination, but this difference is particularly visi-ble in case of the internet – they use both official and informal websites (forums, blogs and social networks). Supporters of vaccination seem to consult medical workers more. This may mean that hesitant parents are more proactive and independent in seeking informa-tion, while supporters of vaccination predominantly rely on official authorities. Quite expect-edly, hesitant parents trust most of the available sources less than supporters of vaccina-tion. This is most striking in case of traditional media (TV, print).

Preferred communication channels. Parents claim that they need more information about vaccination, through all available channels. Supporters of vaccination seem to prefer written material available in health institutions (brochures, posters), while hesitant parents prefer interactive materials (parent forums, websites where they can ask questions). Both groups would like to have more time to speak to their paediatrician.

Determinants of future vaccination-related behaviour. Correlation matrices and re-gression analysis suggest greater importance of psychological measures than of

11Executive Summary

sociodemographic characteristics in predicting future behaviour regarding vaccination. Compared with psychological variables, sociodemographic variables are significantly less related to future behaviour: neither the number of children in the household nor age, edu-cation and socioeconomic status of parents are reliable predictors of future behaviour. One weak, but significant correlation has been detected in case of urbanity – hesitant parents are more likely to live in urban areas. Assessment of risk of vaccination, trusting in myths, theories of conspiracy, media literacy and knowledge about vaccines can mainly predict fu-ture vaccination-related behaviour of parents; perceived support of the surroundings and confidence in official authorities somewhat less; while all sociodemographic variables can't offer much in this aspect. The strongest barriers to vaccination are assessment of the risk of vaccination and trust in myths and conspiracy theories about vaccines. Protective factors are mainly confidence in the official medical authorities and science, as well as perceived support of immediate and broader surroundings. Knowledge about vaccines is not related to future behaviour – being aware of accurate information doesn't positively relate to the intention to vaccinate, but believing in inaccurate (myths and conspiracy theories) under-mines it to a great extent.

Roma parents’ specific experiences with the health system. Roma parents reported positive experiences with vaccination, like those from general population. They are some-what less likely to take their children for vaccination to health centres and more likely to be reminded by the relevant institutions. ). Despite highly positive experiences, only 72% of Roma parents took a child to vaccination on their own following immunization calendar (compared with 88% in the general population). It is obvious that the health system is mak-ing efforts to increase immunization coverage of Roma as almost one third of Roma received written notification to bring their children to immunization. More than 90% of Roma children have a health insurance card, but one out of five parents claim that it was difficult to obtain the card. There are not many testimonials about drastic experiences of discrimination in medical institutions. However, one-third of Roma parents are under the impression that they were left to wait longer in health centres than general population, and that they were treated impolitely. As the main barriers to vaccination, Roma parents specify insufficient information and inadequate time management. Roma parents did not complain that the health centres were too remote or hard to reach. Health mediators are active in a number of communities. However, in the communities where they are visible, their activities are evaluated extreme-ly positively. They visit families in Roma communities regularly, they remind them of the im-munisation calendar and aid with vaccination. Roma parents report of fewer risks and more benefits of vaccination in comparison to general population. They claim that they accept of-ficial medical recommendations as necessary and don’t question them much. They report having strong confidence in medical workers and scientific achievements. Myths and con-spiracy theories are less widespread among Roma parents. They are also more likely to be-lieve that their surrounding supports vaccination, religious leaders especially. They typically perceive non-vaccination to be an irresponsible parental practice.

Roma parents are less likely to read newspapers, and a lot less likely to use the internet, but they trust all sources of information more than general population. Their average score on the knowledge scale is significantly lower than average of general population. Almost half of them can’t answer any of the seven questions, and 90% of Roma parents can’t answer two questions or less. They are also less advanced media users – they neither question the sources of information nor seek additional information. As for collecting information about vaccination, Roma parents would like to talk to their doctor more, and they would also sup-port vaccination that takes place directly in their communities.


V Recommendations

Evidence-based communication

Drawing from quantitative and qualitative data, the main concerns related to vaccination in the three clusters of parents – opponents of vaccination, the hesitant and supporters of vac-cination (Picture 1.1) have been identified. They should serve as a guidance in selecting the main focusses of communication with these specific clusters of parents.

Picture 1.1 – Clusters of parents by the presence of specific barriers towards vaccination

Source: http://www.SZO.int/mediacentre/factsheets/fs378/en/

High Medium Low

Worry aboutdiseases(VPD*)

Worry aboutthe effectsof vaccines

Mistrust inpediatricians

Mistrust inthe health

system

Mistrustin science

Mistrust inpharmaceutical

industry

*VPD – vaccine-preventable diseas

Opponentsof vaccination

Hesitantparents

Supporters ofvaccination

While supporters of vaccination are primarily concerned about the possibility that their chil-dren may get some vaccine-preventable disease, and opponents of vaccination about the adverse effects of vaccines, hesitant parents worry about both. This group of parents trusts paediatricians and medicine fully, they have somewhat less confidence in the health sys-tem, and even less in pharmaceutical industry (of all institutions, pharmaceutical industry has the most negative image in public).

Recommendations about communication contents (WHAT)

The aim of the communication is empowering parents who doubt, worry and hesitate to vaccinate their children to do this, without sensitizing majority of population who vaccinate their children to antivaccination contents. We do not insist on communication with extreme opponents of vaccination, since research results suggest that, when faced with arguments in favour of vaccination, their opinion is either radicalised or remains the same.

13Executive Summary

It is important to adopt different communication strategies for broad public and with hesitant parents:

■ when communicating with the public, insist on dangers of vaccine-preventable diseases, as well as on extensive immunization coverage in EU countries and support that vaccination has in Serbia (according to the results of this research),

■ specific concerns of hesitant parents should be addressed in direct communica-tion between doctors and parents

■ Vaccination should be presented as taking care of children, as the best way to protect one’s own and other children, as a tool at parents’ disposal, which wasn’t available to parents in the past (it is highly efficient to tell anecdotes or show photos of parents waiting for vaccines against polio or pertussis).

Concrete recommendations for communication with the public should rely on two types of appeals: emotional and rational:

■ The rational appeal includes informing of parents – using adequate wording, fair, transparent, but within the limits of their initial interest. Moreover, it includes as-sistance with decision-making, especially regarding risk assessment. Keeping parents informed about extensive vaccination coverage and public support to vaccination, can facilitate the so-called descriptive norms (the idea of what ma-jority of people are doing), which tend to be more efficient in changing behaviour than the so-called prescriptive (what should be done).

■ The emotional appeal includes two components: one is illustration of the con-sequences of vaccine-preventable diseases, and the other is empathising with parents and empowering parents to make the decision.

Brochures available to paediatricians may answer two groups of questions: questions asked by all parents, and specific questions asked by hesitant parents.

As for the training of medical workers, it is necessary to improve its quality and prevent its transformation to forums for spreading of myths and doubts. It is necessary to engage medical schools and faculties, as well as experts for communication. Questions about vaccination may be included in the tests for pupils, students and post-graduates. It should be insisted on the fact that communication with parents about vaccination is doctors' responsibility, that this is not a private and personal decision of each individual, but a decision about public health. Doctors should be empowered in this process, they should be trained to communicate successfully, supplied with adequate materials and informed about relevant digital contents. They should be provided with brochures that will facilitate communication and equip parents with written material that answers most of their questions. There is also the need for opening a line of communication between doctors and higher healthcare institutions that they can address should they have any doubts

Recommendations about communication channels (HOW)

Instead of extensive investing in TV promotion, which means difficult targeting of specific segments of the audience and usually gains disproportionate to the investment, communication with the public should be conducted “below the line” – for example, via billboards displayed in public places. Special effort should be paid to creating visible pro-vaccination Internet


content. The official health institutions engaged in the process of immunization need to include information about vaccination in their web pages, with frequently asked questions and answers to typical parents' fears and arguments of the anti-vaccination movement. Parents should be reached through posters displayed in health centres, schools, through brochures and paediatricians. In line with the trends of automatization, parents can receive an SMS or email instead of being called – investments in these systems pay off quickly, so they were successfully introduced in many developing countries (On the other hand, given that new digitalized medical ID doesn’t enable parents to be reminded of the vaccines and when the child has received them, it would be good to introduce personal paper records. Talking about vaccines can be also included in the program of parenting schools, so that future parents can be informed about the calendar of immunization in time and have their potential worries addressed. Workshops for paediatricians should be more frequent and they should particularly address the skills of communication with parents.

Institutional recommendations

Reinforce the system of procurement of vaccines – interruptions of supply and procurement through private sector had negative effect on the confidence in the system and opened a public discussion about the quality of available vaccines, which was misused by the anti-vaccination lobby for its promotion. Every future interruption of supply threatens to annul the effects and investments in communication/public marketing of vaccines and vaccination. Each such situation requires additional and intensive communicational response («crisis communications») in order to retain confidence and react adequately to the questions that arise.

Continue working with Roma mediators and community-health nurses. by expanding of network and providing support to the current, with permanent availability of information about vaccines in the language and in the way most acceptable to Roma population.

Strengthen the leadership role of Batut (Institute of Public Health of Serbia) through more inclusive and more transparent process of working on doctrinaire, legal and professional acts. This process should also include the media, associations, civil sector, but also health insurance and insurance companies and other stakeholders with important role in promotion of vaccination in developed countries (vaccines are relatively cheap, they reduce the risk of diseases, and thus insurance costs).

Evaluate implementation of the decision about mandatory vaccination. The focus should be on the format of invitation to vaccination; measures following rejected vaccination aimed at explaining parents why vaccination is necessary; penal measures; refund/compensation in case of severe adverse effects; using forms (no standardization) for rejecting vaccination, as well as abandoning the practice (where it still exists) of using forms for accepting vaccination.

15Background and Rationale

Background and Rationale

The vaccine stimulates the immune system to produce the antibodies that further protect the vaccinated person from a certain disease. If the majority of the population in a community is vaccinated against a disease, the whole community will be protected, including those who have not received the vaccine. Vaccination is a proven, cost-effective public-health strategy that has dramatically decreased childhood morbidity and mortality worldwide. Following the Smallpox Eradication Campaign, the World Health Organization (WHO) took a leading role in launching the Expanded Programme for Immunization (EPI) in 1974. This initiative increased the reach of vaccination programs globally, in terms of both geographic and population coverage, and expanded immunization programs to protect children against six childhood diseases: polio; measles; neonatal tetanus; diphtheria, pertussis and tuberculosis.

Health benefits of immunization are well known and backed up by extensive clinical and epidemiological studies. These direct benefits include: 1) dramatically reduced diseases and mortality rates for many infectious diseases, 2) reduced child mortality- the estimated 6 million deaths of children fewer than 5 years of age are prevented, each year, 3) reduction in economic and social burden of disease, through protection against infectious diseases, reduction in health care cost and work-related productivity loss. The indirect health benefit is reduced disease among those who have not been vaccinated. Social benefits of immunization are also very important. They include prolonged life, reduced work absenteeism, safer travel and human mobility, economic growth, promotion of equality, and enabling and strengthening women empowerment.

Despite all mentioned, vaccine-preventable diseases (VPDs) continue to pose a threat worldwide, evidenced by outbreaks of infectious diseases. In the WHO European Region, which includes 53 Member States with traditionally high immunization coverage, the resurgence of measles, rubella and pertussis, each a highly transmissible VPD, shows that these risks are real. Today, immunization seems to be the victim of its own success. In the past years, the level of immunized people dropped worldwide. To be effective it is important to have high immunization coverage (above 95%), both on local and global levels. Current immunization coverage rates in the WHO European Region are insufficient to ensure herd immunity and halt the spread of VPDs in the Region. In some countries with previously high coverage, rates have now fallen well below the 95% WHO-recommended threshold. Overall, in the European Region, an estimated 700 000 – 1 000 000 infants born each year (2012 estimate) do not receive all mandatory vaccines.

Anti-vaccination behaviour may have different forms and intensity. Studies reveal a range of different “degrees” of accepting or rejecting vaccines (UNICEF, WHO): 1) regular immunization by the calendar with all stipulated vaccines, 2) cautious immunization, accompanied by careful collecting of information, but receiving all vaccines in time, 3) hesitating to vaccinate children, being late with some vaccines, 4) selective vaccination of children (accepting some vaccines, and rejecting others), and 5) complete rejection of all vaccines.

2


Despite the proven effects of vaccination, public resistance to vaccination has been present since its very introduction. A typical historical cycle of the disease outbreak, epidemic, development of a vaccine, suppressing of disease, development of suspicion in safety of the vaccine and the repeated outbreak has been identified in history. Typical barriers to vaccination are: fear of side effects; lack of science literacy and distrust in science; lack of scientific information/lack of knowledge; conspiracy theories about the vaccination; mistrust in health system; mistrust in political system and institutions (political anomie); conspiratorial mentality; religious affiliation; cultural myths about the harmfulness of vaccination; media coverage. The World Health Organization warns that the risks of immunization receive disproportionately greater media attention than the positive effects of immunization. In addition, Internet has made healthcare information generally available, but the status of true and false information is equal, science and pseudoscience are not clearly separated, and experts and laypersons occupy equal space and potentially have equal influence.

2.1. Immunization in the Republic of SerbiaAccording to the applicable law in the Republic of Serbia, from the birth of a child to the age of seven, ten vaccines are mandatory and the additional three are recommended (Table 2.1.1 features an overview of the dynamics of immunization at this age, with the addition of HPV vaccines recommended for older age).

Mandatory vaccination

Age Type of vaccine

At birth BCG–against tuberculosisHB –against hepatitis B (the first dose)+ HBIG

2nd month HB –against hepatitis B (the second dose)

3rd monthDTP – against diphtheria, tetanus, whooping cough (the first dose)

OPV -against poliomyelitis (the first dose)HIB - against diseases caused by Haemophilus influenza type b (the first dose)

3 ½ monthsDTP – against diphtheria, tetanus, whooping cough (the second dose)

OPV - against poliomyelitis (the second dose)HIB - against diseases caused by Haemophilus influenza type b (the second dose)

5th months (until 6th month)

DTP – against diphtheria, tetanus, whooping cough (the third dose)OPV - against poliomyelitis (the third dose)

HIB - against diseases caused by Haemophilus influenza type b (the third dose)HB - against hepatitis B (the third dose)

2nd year (12-15 months) MMR - against measles, mumps and rubella

2nd year (17–24 months) DTP – against diphtheria, tetanus, whooping cough (the first revaccination)OPV - against cerebral palsy (the first revaccination)

7th year (before enrolment in school)

DT – against diphtheria and tetanus (the second revaccination)OPV- against poliomyelitis (the second revaccination)

MMR - revaccination against measles, mumps and rubella

Table 2.1.1 – Calendar of mandatory and recommended immunization of children aged from 0 to 7 years in the Republic of Serbia


Recommended vaccination

Age Type of vaccine

From 2 to 6 months (3 doses)


Above 24 months (1 dose)

Against pneumococcus


For older (3 doses)Against HPV (the only one for older age)

For 12+ months(2 doses at 6

months interval)Against Hepatitis A

For 12+ months Against varicella

Source: www.batut.org.rs (April 2017)

Law on Protection of Population from Contagious Diseases (http://www.zjz.org.rs/wp-content/uploads/2013/04/Zakon-o-zastiti-stanovnistva-od-zaraznih-bolesti.pdf) and the Rulebook on Immunization and chemo-prophylaxis (http://www.rfzo.rs/download/pravilnici/mz/Pravilnik_imunizacija-15042015.pdf) determine which vaccines are mandatory in Serbia and which ones are recommended. The Law on Rights of Patients clearly stipulates that patients have the right to decide freely about all aspects of their health and health protection, except in cas-es when this is life-threatening and/or threatening the health of other people. Vaccination is recognised as this special case because the person who rejects vaccination can become a carrier of the infectious agent to other people whose infection can have a fatal outcome.

Nevertheless, according to some interpretations, the parent or caregiver can refer to The Law on Rights of Patients and refuse administration of a certain vaccine to the child, which is verified by completing the appropriate form/application by the parents or caregiver. If this is the case with vaccine from the mandatory program, such parents are reported to health inspection, which, after the expert supervision and additional counselling with the parent, can be referred to the competent judicial authority. If this is the case with one of the recom-mended vaccines, such procedure will not apply.

During the year 2016, a total of 686 controls were carried out and 200 parents were sent to court. Although the law provides for penalties from 30,000 to 150,000 dinars (USD 300-1,500) for the parents who refuse vaccination, most charges ended with the warning note of the Court requesting supplementary counselling service with health professionals on the issue of vaccination. Finally, Serbian legislation recognises “the best interest of the child” (which includes vaccination) when parents or caregivers lose the right to make ul-timate decisions in the name of the child. There are no available data on whether, upon court order, there were children who were immunized against the wish of their parents, and Constitutional Court of Serbia, in its release from 2015, announced that it had not dealt with such cases before (http://rs.n1info.com/a49707/Vesti/Ustavni-sud-o-vakcinama.html).


% 2011 2012 2013 2014 2015

Against tuberculosis 98.6 97.9 97.5 97.6 98.3

Against poliomyelitis

Vaccination 97.6 93.7 97.4 95.1 94.9

Revaccination 2nd year 95.9 92.2 92.9 90.6 83.8

Revaccination 7th year 98.1 96.3 96.0 95.3 90.8

Against diphtheria, tetanus & pertussis

Vaccination 97.5 95.9 96.9 95.0 95.0

Revaccination 2nd year 95.9 93.1 93.1 90.3 88.7

Revaccination 7th year 98.4 96.9 96.1 95.2 92.8

Against measles, mumps and rubella

Vaccination 96.5 90.4 93.6 85.8 84

Revaccination 7th year 98 94.2 84.1 89.2 87.5

Against hepatitis B Vaccination 96.4 93.1 93.4 93.9 91.5

Against Hib Vaccination 96.5 91.3 94.7 95.2 94.1

Table 2.1.2 – Coverage on the territory of RS from 2011-2015 (IJZ Batut)

Surveys of the Institute for Public Health Batut primarily deal with the behaviour of people related to vaccination and its medical consequences, following and analysing immunization coverage in the Republic of Serbia. Researchers from Batut integrate the annual reports from local public health institutes on immunization coverage. The objective of systematic immunization in the Republic of Serbia according to Batut is to achieve and maintain the coverage of 95% on the level of the entire population of children according to the Calendar of immunization.

The last report of IPH Batut indicates a decrease of immunization coverage in the year 2015 compared to preceding years; the data are shown in Table 2.1.2 (the data about im-munization coverage in 2016 still haven’t been made available to the public), accumulation of particularly vulnerable groups and the risk of an outbreak of epidemics. It is particularly worrying that coverage for some vaccines is below the level of the preceding year and the lowest in the ten-year period. Batut report concluded that, as a consequence of the decline in the quality of collective immunity of population against certain infectious diseases, spo-radic and/or epidemic of vaccine-preventable diseases (measles, pertussis) is reported. This alarming information is followed by continuous compromising of immunization in the professional, general and adult population. All mentioned facts undermine the sustainabili-ty of the strategies outlined in the national action plans according to the recommendations and requirements of the WHO for the European Region. It is further stated that the Republic of Serbia has had traditionally good results in immunization coverage, which are currently


decreasing due to several reasons. It is also claimed in the report that limited and inade-quate response of the medical and professional public to demands of WHO has contribut-ed to such situation. An interruption in the continuity of immunization caused by shortage of vaccine, problematic distribution and refusal of immunization, as well as the anti-vaccina-tion lobby, jeopardize the sustainability of the achieved target values of vaccination cover-age according to national immunization calendar.

The Batut report comments the decrease in MMR vaccine coverage. The main cause is the interruption of distribution and stock-outs of MMR vaccines and refusals of vaccination with this vaccine because of alleged connection with autism. There are also comments about the decreasing trends compared with previous years regarding other vaccines. The import-ant reason for this is the unavailability of some vaccines for the planned population. Other barriers are: place of immunization (school children are usually vaccinated in health centres and not in schools), inconsistent and indecisive attitude of some paediatricians in the pri-mary health care and their inability to communicate with indecisive parents, as well as me-dia activity of anti-vaccination lobby. We should also mention the high-risk populations that cannot be immunized, so it is clear that there is a critical mass of not vaccinated population and that the immunization coverage trend is negative. Batut specifies some positive prac-tices aimed at coverage increase realised in 2015, such as: revision of vaccination files and supervisory visits, introducing immunization week in Serbia, etc.

Out of the total of 17 measures proposed by the Public Health Institute that may contribute to bigger immunization coverage, five refer to upgrading of continuous availability of vac-cines in healthcare institutions, three to necessary amendments of legal procedures that may improve the availability of vaccines, and even six refer to communication and educa-tion of parents, but also of medical workers. The experts from Batut believe that it is nec-essary to examine more closely general and professional public, primarily the domain of their attitudes, motives, knowledge, to obtain guidelines for future action of the profession-al public.

The Batut data are complemented by the MICS data in the year 2014 (MICS, 2014, Table 2.1.3), primarily in the domain of collecting data about very vulnerable and at-risk groups, but also the data referring to vaccination timeliness and full coverage (Roma population).


Table 2.1.3. shows that 81% of children below 35 months of age received all recommend-ed vaccines at the time of MICS survey, while 71% of children received all recommended vaccines before their first birthday (or second birthday in case of measles). In Roma settle-ments, 44.1% of children below 35 months received all recommended vaccines at the time of the survey, while only around 13% of children from Roma settlements received all recom-mended vaccines on time before the first birthday (second in case of measles).

The coverage with single vaccines, except for vaccines against tuberculosis (BCG) and hepatitis B (HepB), is lower than 90% and it is reduced for the second and the third dose. For instance, the coverage with the first dose against DTP is 87%.

The data from Batut and MICS studies are mostly aligned despite different methodologies, although MICS data suggest somewhat higher coverage of certain vaccines since their methodology allowed for a wider revaccination period.

MICS Indicator Description Serbia Serbia – Roma settlements

3.1 Immunization

coverage against tuberculosis (BCG)

Percentage of 12-23 months old children who have received BCG vaccine before their

first birthday (before the age of 1 year)98,0 94,3

3.2Immunization

coverage against polio (OPV)

The number of 12-23 months old children who have received the third dose of OPV vaccine (OPV3)

before their first birthday (before the age of 1 year)86,4 61,0

3.3

Immunization coverage against

diphtheria, pertussis and tetanus (DTP)

Percentage of 12-23 months old children who have received the third dose of DTP vaccine (DTP3)

before their first birthday (before the age of 1 year)87,4 64,5

3.4

Immunization coverage against measles, mumps

and rubella (MMR1)

Percentage of 24-35 months old children who have received MMR1 vaccine before

their second birthday (12-23)93,4 63,3

3.5Immunization

coverage against hepatitis B (HepB)

Percentage of 12-23 months old children who have received the third dose of

hepatitis B vaccine (HepB3) before their first birthday (before the age of 1 year)

91,3 67,8

3.6

Immunization coverage against meningitis (Hib – Haemophilus influenza tip B)

Percentage of 12-23 months old children who have received the third dose of Hib vaccine (Hib3) before their first birthday (before the age of 1 year)

80,4 49,6

3.7Full immunization

coverage

Percentage of 24-35 months old children who have received all recommended vaccines from

the national calendar of immunization before their first birthday (second birthday in case of measles)

70,5 12,7

3.8Full immunization coverage at the time of survey

Percentage of 24-35 months old children who have received all recommended vaccines from the national calendar of immunization

80,6 44,1

Table 2.1.3 – Immunization coverage by MICS 2014


2.2. Rationale and Aims of the ResearchThe available data clearly point to the decreasing trend of immunization in the Republic of Serbia, the pattern observed in many other countries in Europe. Some of the barriers to vac-cination were described in international literature but their true influence on population in Serbia has never been thoroughly researched.

Availability of such information would be a key prerequisite for initiation of a dialogue be-tween the health system and its users - the wider community - on removing myths and distrust over the necessity and safety of the vaccination. A proactive approach to commu-nication can help alleviate the negative impact of rumours and misinformation on the im-plementation of immunization. The research findings will serve as the basis for the devel-opment of messages and materials for public advocacy campaign and social mobilization.

The research was implemented with an aim to generate and document evidence on the existing attitudes and practices towards immunization among caregivers/parents from the general population, vulnerable groups (the poorest households, Roma communities) and health professionals as an evidence base for development of messages and materials for public advocacy campaigns and social mobilization.

More specifically, the survey attempted to find out:

■ What is the existing knowledge, attitudes and practices on immunization in Serbia among parents of children aged 0 to 7

■ What are the barriers and bottlenecks in immunization of children (at the individ-ual, community/societal or institutional level);

■ What are vulnerabilities and gaps in knowledge, attitudes and practices among different ethnic/socio-economic groups and geographic areas;

■ What are the areas of interest for public advocacy and social mobilization campaigns

■ What are the preferred channels of communication and forms for placing health information adapted to specific audiences / groups of parents / key informants.

The key research questions included the following:

■ What were the previous immunization experiences of parents of children aged 0-7 and what were the bottlenecks they faced (with specific bottlenecks relevant for Roma population), to what extent the past experiences correlate with their intended future behaviour

■ What was the previous immunization practice and what is intended future vac-cination practice

■ What are beliefs, causes of concern and attitudes of parents about key aspects related to immunization;

■ What are the most used information sources, what are desired sources of infor-mation and what are the specificities for different target groups of the population

■ What is the level of knowledge about immunization


■ What is the level of trust in different actors important for immunization

■ How do different aspects of knowledge, beliefs and attitudes and the level of the perceived risks correlate with the past or intended immunization practices

The main focus of the research was collection of data from parents (primarily mothers) of children aged 0-7 years through focus group discussions and “face-to-face” interviews. A small number of health professionals were included in the research only as key informants, as an agreement on their inclusion through a quantitative survey on a larger sample was not reached with the Ministry of Health.

The inability to include a larger sample of health professionals is one of the research lim-itations since they are in a daily interaction with parents and larger number of respondents would create a more robust basis for conclusions on strengths and weaknesses of the health system and providers of health services in relation to immunization. Second limita-tion relates to the sample size for the quantitative survey with parents. Due to limited re-search resources, the sample was designed to have a minimal size which still meets the requirement of a nationally representative sample. Due to a relatively low sample size, num-ber of cases on some cross-tabulations is too small to allow for interpretation.

The research results should empower the key stakeholders involved in the immunization process in Serbia – the Ministry of Health, the Institute of Public Health and the network of regional institutes of public health, the University Clinic for Children from Belgrade. The re-search findings will also be used by UNICEF and WHO in their efforts to support the gov-ernmental stakeholders to desing communication messages and approaches aimed at at-taining larger immunization coverage.

23How the research was conducted

3 How the research was conducted

3.1. Management and Quality Assurance The research was implemented by IPSOS Strategic Marketing which deployed the team of researchers and field staff for the realization of all survey components. The managing team consisted of employees in Ipsos Strategic Marketing, experts in the area of statistics and psychology, with wide experience in methodology and survey design, conducting quantita-tive and qualitative surveys in the area of public affairs, data collection, statistical analysis and reporting. The managing team also included three consultants in psychology and med-icine to assure additional quality of this research. Structure of the managing core team is described in the table below.

Beside this core management team, it is also important to mention something about field-work manager and managers from scripting and data processing departments in Ipsos Strategic Marketing.

- The field manager was in charge of managing the data collection process for the quantita-tive phase of the research. This task included monitoring and control of field work on daily communication with coordinators and interviewers (a total of 60 interviewers and 6 regional coordinators), which enabled the whole process of work on the field passes smoothly.

- Head of the scripting department in Ipsos Strategic Marketing Scope Department was in charge of data entry, encryption, writing scripts for data entry, writing scripts for data entry SM-S, managing the data processing and data clearing, logical control, database format-ting. She was also in charge of making all personal data obtained through data collection anonymized. Standard procedures for data privacy are applied as follows:

■ Ensuring that respondent identifying information is securely and permanently deleted when it is no longer necessary to retain it for this research.

■ Secure the permanent anonymization of the research data.

■ Secure storage and transfer of personal data throughout the project

- Head of the data processing department at Ipsos Strategic Marketing, was in charge of coordinating data processing, data processing and analysis. focussing exclusively on tabu-lation and reporting, giving these tasks the importance they require.

Keeping focus on data from qualitative phase (like transcripts and audio and video materi-als) once they were transferred to ISM server, all materials were permanently erased from audio and video devices. Data on Ipsos server were protected by the password, and ac-cess to these files was granted only to the members of the research and recruitment team. For research purposes transcripts were made from audio materials. Persons who made


transcripts are employees of Ipsos who are legally obliged not to share with anyone except the members of research team the materials which they listen to or watch to make tran-scripts. They also have a legal obligation to keep strictly confidential the privacy and identi-ty of all participants in FGDs and IDIs, since they are forbidden to share personal informa-tion about survey participants. Finally, the persons who make transcripts are in obligation to erase all materials permanently from their computers once they finish with them.

Ipsos Strategic Marketing is the largest research company in the region concerning the number of conducted researches, total number of realized interviews and total number of clients. The management team which was included in this research followed the highest professional ESOMAR and ISO (International Organization for Standard) standards, con-cerning survey design, data collection, processing and analysis. Compliance in this re-search was centrally managed and monitored by a dedicated compliance and information security department, and was subject to regular spot checks, internal audits and external assessment by an external audit certification body against the requirements of the interna-tional standards for:

■ Market research process quality standard, ISO 20252:2006

■ Information Security, ISO 27001:2005 (previously ISO 17799)

A central component of Ipsos integrated quality, compliance and information security man-agement system was to ensure that all processing of personal data is carried out in compli-ance with all applicable data protection and privacy laws, including the Republic of Serbia Law on Protection of Personal Data and national equivalents.

In this process, Ipsos Strategic Marketing provided the support by ensuring clear and strin-gent project specific processes to ensure compliance, which included:

■ Ensuring that respondent identifying information are securely and permanently deleted when they are no longer necessary to retain for this research.

■ Secure and permanent anonymization of the research data.

■ Secure storage and transfer of personal data throughout the project, which in-cludes making sure that any necessary hard copy documents containing per-sonal data are returned our Head Office using a secure courier service.

Details about steps which were included in the research process to provide the protection of human subjects and protection of the data are described in section 5 - Research ethics. It is also important to point out the fact that, during the whole research process not a single adverse events have happened, and that research was conducted without any problems.

Quality Assurance Process

Although this research was not tagged as a “major” research as per UNICEF criteria, the quality assurance process included peer reviews at different stages. The initial ToR of the research was revised in the inception phase following consultation between the Ministry of Health, the Institute of Public Health and UNICEF as an agreement to include a quantitative survey with health professionals was not reached. The Inception report (Technical propos-al) included the new scope for the research implementation and was reviewed by UNICEF Serbia and ECARO technical staff. UNICEF Serbia staff were closely involved in develop-ment of research instruments and approved the final versions. UNICEF Serbia staff were also closely involved in data analysis phase.


The preliminary findings and recommendations (draft report) were presented at a consul-tation meeting with the key stakeholders in Serbia (Ministry of Health, Republic Institute of Public Health, WHO, University Children’s Hospital, City of Belgrade Institute of Public Health, key experts etc.) and all comments shared during that occasion were considered when preparing the final version of the report. The draft report was reviewed by UNICEF Serbia and ECARO technical staff and the draft final report was revised in line with the re-ceived comments. As the last stage of the quality assurance process, the draft final report was also reviewed and revised in line with the comments provided by IOD Parc as an exter-nal quality assurance facility contracted by UNICEF.

3.2. Literature review of previous research on vaccination coverage and public communication strategiesImmunization is the process of protecting people from infective diseases through vaccina-tion and it is often seen as one of the three most important medical achievements (Wade, 2014). The vaccine stimulates the immune system to produce antibodies which further pro-tect the vaccinated person from infectious diseases. If the majority of the population (above 95%) is timely and fully vaccinated, the whole community will be protected from the spread of disease, including those who, for some reason, have not received vaccines.

The impact of immunization on public health is obvious – it dramatically reduces the inci-dence and mortality from infectious diseases. Moreover, vaccination has additional positive effects, both on the variety of different social phenomena and on general well-being of a community.

Despite proven benefits of vaccination, public resistance to it has been present since its very introduction. Discussions about benefits and risks of vaccination are particularly perti-nent and complex today, in the era when media and global communication are in full bloom. Increasingly, public discussions lead to lack of public trust in medical services, the decline in vaccination coverage and consequent recurrence of diseases that have almost been eradi-cated. Scientists and health professionals so far managed to overcome the problem of pub-lic resistance to vaccination with varying success. Leading authorities in the field argue that nowadays, with vaccines and health services widely accessible, public communication is the most important determinant of immunization programs success. To reach and maintain high coverage of national immunization programs, it is of utmost importance to constantly survey public opinion, and to tailor communication and educational activities accordingly.


3.2.1. Effects of immunizationThe vaccination was introduced in the 18th century in Great Britain. Since then, numerous benefits of immunization have been well documented and scientifically proven. Direct ben-efits are prevention, control, elimination and eradication of contagious, often fatal dis-eases. While complete eradication of the diseases on global level is the most desirable out-come of immunization (as in the case of smallpox or polio), elimination of the disease is an important goal that can be set up for individual regions (e.g., measles in the Americas and Europe) or individual countries (e.g. Finland). However, local elimination is difficult to sus-tain, as there remains a risk of recurrence of the diseases that can easily be imported from other regions where vaccination is not carried out in an optimal way. In other words, it is im-portant that immunization coverage is high, both on the local and global level because no community lives in isolation from others.

Additional health benefits of immunization are: reducing child mortality (which is im-portant both on individual and on the social level: some scientists estimate that immuniza-tion annually prevents the death of over 6 million children under 5 years of age around the world); savings in health funds due to reduced morbidity and disease outbreaks. Immuni-zation not only protects those who have been immunized, but it can also protect those who have not been vaccinated – this, so-called "herd immunity” occurs when vaccination cov-erage is high enough. It is also possible to perform selective immunization in case of out-breaks, with an aim of eliminating the source of disease ("source drying"). Immunization also provides protection against related diseases (e.g. Hib vaccine reduces the risks of re-spiratory infections caused by some other agents) and increasingly, vaccination offers pro-tection against malignant diseases at a later stage in life (e.g., hepatitis B as the cause of liver cancer). Vaccination has a proven impact in reducing overuse and resistance to antibi-otics which is a growing global threat.

“Social benefits“ of immunization are not negligible either, and they are the following: ex-tending the life span of population, reducing absenteeism from work due to illness, facilitat-ing safe travel and human mobility (air transport allows people to travel to different parts of the world, exposing themselves to illnesses that they do not encounter in their usual environ-ment), economic growth (good health of population has an impact on economic growth), pro-motion of equality (infections and diseases affect the poorest segments of population and the most marginalized ones disproportionally; if immunization is accessible to everyone, it would improve health equity), women empowerment (immunization has important effects on health of children and dramatically reduces child mortality – their chances of being healthy and ex-periencing adolescence increase; as a consequence, women decide to have fewer children. This has a major impact on the educational and economic growth of a country).

Despite all the achievements, immunization nowadays seems to be the victim of its own success. The World Health Organization warns that today, in the era of global communica-tion, the risks of immunization receive disproportionately greater media attention than the positive effects of immunization which are enormous and numerous (Andre et al., 2008).

The World Health Organization and UNICEF systematically monitor the immunization cov-erage throughout the world (Figure 2.1.1). The percentage of immunization coverage in the world depends on the type of vaccine and it is the highest against polio, tetanus and diph-theria (total 86%), for measles and rubella 85%, for hepatitis B 82%. For newly introduced vaccines, the coverage is (expectedly) lower: 31% for pneumococcal and 19% for rotavirus vaccines.


Figure 3.2.1 – Vaccination coverage worldwide (WHO, 2016)

Source: http://www.SZO.int/mediacentre/factsheets/fs378/en/

Measles

Hepatitis B

Polio

Difterija-tetanus

Pneumococcal

Rotaviruses

0% 18% 36% 54% 72% 90%

86%

86%

85%

82%

31%

19%

0

60

80

100

40

20

Africa EuropeAmerica Asia

Figure 3.2.2 – DTP3 immunization coverage in urban areas by continents and wealth (WHO, 2016)

Urban poorest 20% Urban average Urban richest 20%

Source: http://www.SZO.int/gho/urban_health/services/dpt3_vaccination/en/

DTP3

immu

nizat

ion co

vera

ge (%

)

The coverage of immunization depends on a number of factors, and there are groups which are especially vulnerable and hard to reach. The World Health Organization and UNICEF monitor the geographical coverage of all types of vaccines (by continents), but also accord-ing to other important determinants (settlement type, education level, ethnicity, SES ...). To give an example, Figure 3.2.2. shows coverage by DTP3 vaccine by continents and type of settlement. The highest coverage was observed in the European Region and among the ur-ban and well-off population on all continents (above 80%). On other continents, particularly in Asia and Africa, the percentage of vaccinated population among the poor population cat-egories is considerably lower, and it ranges from 65% to 75%.


0

60

80

100

40

20

Africapoorest

20%

Africarichest

20%

Americapoorest

20%

Americarichest

20%

Asiapoorest

20%

Asiarichest

20%

Figure 3.2.3 – Vaccination trends, 1990-2011 (WHO, 2016)

1990-1999 2000-2011

Source: http://www.SZO.int/gho/urban_health/services/dpt3_vaccination/en/index1.html

DTP3

immu

nizat

ion co

vera

ge (%

)

Although in general, they are increasing, trends in vaccination coverage are different for different diseases and geographically and economically different populations. As an illus-tration, figure 2.1.3. shows trends in DTP3 vaccine coverage during the two decades (from 1990 to 1999, and from 2000 to 2011): while in Asia a significant increase was recorded among both the richest and the poorest segments of population, in America the increase in coverage was recorded only for the poorest segments, and in Africa no significant chang-es have been made. Besides that, the differences in DTP3 vaccination coverage between the poor and the rich are still dramatic. The first requirement to level the differences is cer-tainly the availability of vaccine; however, when the availability is ensured, and there is no growth in vaccination coverage, the reasons should be looked for in population’s hesitation towards immunization.


3.2.2. Barriers to and promoters of immunizationThe research shows that the factors influencing the decision on immunization are numerous and do not work unambiguously. The barriers to immunization are numerous, so besides monitoring of vaccination uptake and coverage (a proxy indicator for parents’ behaviour), it is necessary to continuously work on creation of familiarity with positive effects of immu-nization. The barriers and the promoters of immunization can be grouped in various ways (Kastenbaum, Feemster, 2015):

■ Parents’ sources of information and knowledge about immunization;

■ Experience with immunization and vaccine-preventable diseases;

■ Medical practice (behaviour and responsiveness of medical workers), confidence in health system; immunization policy (monitoring immunization, access to schools, immunization calendar, mandatory nature of the program);

■ social norms (the community on immunization, the impact of family, religious leaders, the strength of anti-vaccination movements);

Refusal of immunization is associated with a number of factors including religious, cultural and educational factors, but also with socio-economic status (SES), which is the dominant factor in certain groups of the population, such as those with low socioeconomic status, in most countries, but also those with very high SES in some developed countries. Information available to the public is definitely of crucial importance for acceptance of immunization pro-cess. Official information (unaffected by the influence of the media and marketing) is very important, particularly when it comes to the quality and the safety of the vaccine, side ef-fects, the efficiency of vaccination compared to other, alternative methods of disease con-trol, as well as rights and obligations of parents.

One of the most comprehensive contributions to understanding the factors leading to the decline in immunization was made by Strategic Advisory Group of Experts (SAGE), the group which was formed by WHO in 2012 with the aim of addressing the growing problems of decrease in immunization coverage. SAGE group provides a meta-analysis of a large number of studies from this field in different countries (Larson et al, 2014), and maps the main barriers to the process of immunization. In their analysis, the barriers are grouped into the following large categories:

■ Contextual impacts (macro factors impacts) - historical, geographical, socio-cultural (religion, culture, influential leaders ...), economic and political factors, as well as the organization of the health system;

■ Personal norms and norms of the groups that an individual belongs to –personal perception of benefits and risks from immunization; impact of important groups (beliefs, attitudes, confidence, awareness, knowledge, social norms)…;

■ Vaccines and vaccination process – characteristics of vaccines and immunization process (calendar of immunization, prices, availability…)

All these factors are complexly interrelated when it comes to their impact on vaccination decision. Results of various studies are summarized in Table 3.2.1.. Namely, studies in various countries show that father’s education, economic factors and lack of knowledge are in correlation with hesitation regarding vaccination. Socioeconomic status is positively


FACTORS Barriers Promoters

Socio-economic status SES USA (high and low SES)Nigeria (low)

Burkina Faso (high)India (high)

Bangladesh (high and low)

EducationChina, Lebanon, Israel, Bangladesh, USA

(high education potentially a barrier)Nigeria, India, China, Kazakhstan

(low education)

India (high education)Greece, Netherlands, Nigeria

Pakistan (high education)

Exposure to communication about vaccination Taiwan, Canada (-) Nigeria, India, Bangladesh (+)

Accessibility and cost Nigeria, India, Pakistan, Greece (long distance to health care facility)

Congo (transport costs to vaccination point)

Knowledge about immunization Congo, ChinaNigeria, Netherlands

Nigeria, IndiaFrance, Canada, New Zealand,

Pakistan, USA, Germany

Social norms regarding immunization

USA, Canada, Netherlands, Great Britain, Taiwan,

Nigeria, Congo (+)

Attitudes USA; Taiwan (-) (+) Italy, UK, Canada, Netherlands, Switzerland

Positive attitudes regarding health China, Burkina Faso, Nigeria, India

Confidence in health system Germany

Awareness of vaccine-preventable diseases Nigeria

Table 3.2.1. – Barriers and promoters of immunization in different countries (Larson et al., 2014)

connected with vaccination in many countries: in other words, people with lower SES typ-ically have more negative attitudes towards vaccination. Nevertheless, in some countries, even high SES results in hesitation towards immunization. Lower SES is connected with lower confidence in the health system and lower education of parents, which can also im-pact the mentioned relation. The level of education in some studies shows positive connec-tion with the degree of immunization, while in some countries the high level of education can even be a barrier to immunization. Exposure to various media can also be a barrier and a promoter of vaccination, depending on the content. Being informed about vaccina-tion seems to be a promoter, but, if the information is not scientific or if it is based on myths from alternative sources of information (websites, forums, blogs, social networks) it turns into a barrier. All these results clearly show that it is not wise to consider sociodemographic characteristics isolated from a wider cultural context and that there are no universal regular-ities that are recorded without distinction everywhere. The impact of the observed factors is complex and contextually specific, it varies in time, and it depends on the country and type of vaccines. This is why periodic and specific studies are needed for each country specifi-cally, and, in order to shed light on the reasons for vaccination, besides quantitative, it would be desirable to include qualitative analyses as well.


3.2.3. UNICEF surveys (KAP- knowledge, attitudes, practices)A number of UNICEF surveys focus on the assessment of knowledge and attitudes of stake-holders related to immunization. Stakeholders are medical workers, children and parents, but also direct and wider social environment, as well as media. Table 3.2.2. shows recent UNICEF surveys in Central and Eastern Europe and CIS Countries. Table 3.2.2 shows dif-ferent methods applied in the surveys, while Table 3.2.3 indicates the key findings. Despite different methodologies and survey objectives, it is safe to conclude that dominant barriers to immunization are very similar in all observed countries.

Country Method Sample Main objective Year

ArmeniaQualitative (FGDs and IDIs 80 participants) General population,

medical workers

Capital city and 10 provinces

Perception, attitudes and practices towards immunization;

Inclusion of new vaccine against rotavirus;

2012.

Georgia

Quantitative (doctors and medical workers

465, 695 parents of children up to 2 years) Qualitative (FGDs and IDIs)

Key informants, mothers, doctors,

media workers (capital city and 2 regions with problems in immunization)

Inclusion of new vaccine against rotavirus in the process

of mandatory immunization; (topics: perception of medical

workers, knowledge and awareness of immunization,

information) KAP survey

2012.

2014.

2016.

Kyrgyzstan Qualitative (21 IDIs) 8 regions Perception and behaviour of parents regarding immunization

Moldova Qualitative (11 FGD, 55 IDIs)

Mothers of children from 1 to 5 years,

doctors, media workers

Introduction of new vaccine against rotavirus; perception,

knowledge and attitudes towards immunization process,

sources of information, doctor-parent relationship

2012.

Table 3.2.2 – Overview of UNICEF surveys in recent years


Table 3.2.3 – Key findings of UNICEF surveys

Country Key findings

Armenia

Profile of opponents to introducing mandatory vaccine against rotavirus: religious groups, parents whose children have problems with diseases which are wrongly associated with immunization to the highest extent (autism), people who accept homoeopathy, influential medical workers who oppose immunization; The main barriers to introduction of a vaccine against rotavirus: insufficient information about the disease.

Georgia

Determinants of decreased immunization coverage: decrease of confidence in health institutions, the use of new alternative sources of information (Internet and social networks), lack of technical abilities and communication skills among medical workers, lack of knowledge about immunization, financial motives as a reason for low immunization coverage in rural and poor and undeveloped areas, lack of knowledge about rotavirus.The main barriers to bigger coverage: lack of straightforward and scientifically based information, concerns about safety of vaccines and effects after vaccination, inadequate understanding of counter-indications as specified on vaccines bought in pharmacies, behaviour of medical professionals (negative information about immunization despite the stipulated rules, blaming the vaccines for children’s health problems, postponing immunization due to bad or inadequate assessment of child’s health condition, recommending vaccines purchased freely on the market); popularity of alternative medicine, particularly homeopathy; religious leaders who oppose immunization.

Kyrgyzstan

Sources of vaccine information for parents: medical workers and brochures in health institutions, media, environment, social networks. Mistrust all sources equally. Vulnerable groups: Migrants are a particularly sensitive group in this process.The main barriers to bigger coverage: negative experiences with immunization, migrations, vaccine shortages. Lack of complete information about immunization, religious beliefs, incompetent doctors who do not provide enough information about immunization, negative influence of friends and relatives (negative social norms), strong conviction that vaccines are primarily the means of profit for pharmaceutical companies and are medical experiments on children, widespread belief that it is necessary to follow the example of ancestors who were healthy although they were not vaccinated .

Moldova

Determinants of decreased immunization coverage: increasing number of patients who turn to alternative medicine (homeopathy) or listen to advice by various religious leaders who oppose immunization (particularly parents whose children had some side effects after regular immunization); unclear vaccination procedures (procedures which need to be implemented if the child has not been vaccinated in time are unclear both to parents and doctors).Profile of anti-vaccination groups: Parents’ fears are well addressed by anti-vaccination movements, initiated by religious leaders or persons who practice alternative medicine. It is necessary for medical workers to have developed and clear protocols on how to act in cases when parents are hesitant whether to vaccinate their children.Vulnerable groups: poorly informed mothers, particularly those from rural areas trust health system more and they vaccinate their children without hesitation, but their attitudes can easily be undermined by information coming from anti-vaccination movement.The main barriers to bigger coverage:: Doubts about the quality of vaccines, doubts that real side effects are hidden from parents (both short-term and long-term effects), poor reputation of pharmaceutical companies, religious leaders who oppose immunization. In addition, irresponsible behaviour of certain medical professionals who do not supply enough information or do not communicate sufficiently with the patients, mothers who think that the doctors do not examine their child thoroughly before immunization, as well as the absence of personalized communication approach.

Ukraine

Effects of POLIO immunization campaign: the visible campaign was assessed positively. Assessment of current vaccination mood. Relatively positive Stable vaccination coverage, knowledge about immunization process on the increase, the main sources of information is doctors and the mass media. Distrust in immunization process and vaccine producers is declining. The main barriers to bigger coverage: The strongest reason for rejecting vaccination is distrust in quality of vaccines and fear of side effects..


3.2.4. Typology of vaccination behaviourAntivakcinalna ponašanja mogu se razlikovati po obliku i intenzitetu. Postoji mnogo modela koji pokušavaju da opišu oblike antivakcinalnih ponašanja i razloge koji stoje iza ovakvih stavova. Antivakcinalna ponašanja obuhvataju čitav niz različitih ponašanja roditelja koja se odnose na imunizaciju dece: jednu grupu čine roditelji koju potpuno odbijaju vakcinaciju, a drugu roditelji koji redovno vakcinišu i revakcinišu svoju decu svim propisanim vakcinama (Kastenbaum & Feemster, 2015). Međutim, bilo bi pogrešno pretpostaviti da su ovo jedina dva oblika ponašanja roditelja vezana za imunizaciju. Studije obično otkrivaju niz različitih „stepena“ prihvatanja ili odbacivanja vakcina:

■ redovna imunizacija prema kalendaru imunizacije svim propisanim vakcinama;

■ oprezna imunizacija, praćena pažljivim prikupljanjem informacija, ali deca na vreme dobijaju sve vakcine;

■ oklevanje da se deca vakcinišu, kasne sa nekim vakcinama;

■ selektivna vakcinacija dece: roditelji neke vakcine prihvataju, druge odbijaju;

■ apsolutno odbijanje svih vakcina.

Svetska zdravstvena organizacija navodi da u ovom trenutku ne postoji puno roditelja u poslednjoj grupi. Stručnjaci sugerišu da pažnju treba posvetiti mnogo većoj grupi roditelja koji se nalaze između dva ekstremna stava, onima koji pokazuju malo oklevanja i potrebu za dodatnim informacijama o određenim imunizacijama.

Zbog toga je neophodno pratiti razloge za različita ponašanja, znanje, verovanja i stavove stanovništva o imunizaciji.

3.2.5. Communication with public about vaccines: history and overview of empirical findingsPublic support to vaccination is not stable and unchangeable. On the contrary, there have been many cases of potential users of vaccines who began resisting or doubting their safe-ty, i.e. who experienced the so-called “vaccine scare”. Resistance to vaccination has been present, for instance, in the USA since 1850, when vaccination against smallpox was con-sidered as a violation of civil freedom. As a response to the attempts of the state to make vaccination compulsory and prevent the epidemic of smallpox, the Anti-vaccination Society of America was established in 1879; there were similar initiatives in Great Britain and in oth-er European countries. In the second half of the 20th century, many vaccines against poten-tially deadly children’s diseases were developed, such as polio, measles, rubella, tetanus, pertussis and tuberculosis. At that time the parents were enthusiastic about vaccination, which resulted in an extensive reduction of disease incidence, the seriousness of symp-toms and mortality caused by these diseases (Kestenbaum & Feemster, 2015). However, the anti-vaccination movements revived during the 70s in Great Britain, when the safety of the vaccine against pertussis was suspected. In the USA, the controversies about the safe-ty of vaccines were stimulated by the documentary “DTP: Vaccine as roulette”, created in 1982, which was supposedly financed by the pharmaceutical industry in order to promote a new type of vaccine.


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Figure 3.2.4 – The coverage of MMR vaccine before and after Wakefield

MMR vaccine coverage (%) Confirmed measles cases in England and Wales

The global anti-vaccination crisis was provoked by the publication of Andrew Wakefield et al. in 1998, published in the journal Lancet, which identified MMR vaccine as one of the trig-gers of autism (Wakefield et al., 1998, retracted).

Although scientists agree that this study is methodologically flawed, that the authors had a conflict of interests and that there are proofs from hundreds of epidemiological studies that disprove this connection, the anti-vaccination movement still insists on unsafety of vac-cines, doubting that the scientific community is unbiased. Due to reduced vaccination cov-erage rate, the percentage of “vaccine-preventable diseases” (VPD) has increased in many countries, primarily in developed countries. The scare of vaccines has its consequences, as was well documented in England and Wales (Figure 2.1.4).

Similarly, when the rumour appeared about the connection of Thiomersal (Thimerosal), a vaccine preservative, and autism in 1999, the number of vaccinated children dropped dras-tically (Figure 3.2.5.).


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Figure 3.2.5 – Coverage of Hepatitis B vaccine before and after launching information about harmfulness of Thiomersal, Larson et al., 2011

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2000Number of children

Joint statement issued regardingthiomersal as a vaccine preservative

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It is possible to identify a typical historical cycle of a disease outbreak, epidemic, develop-ment of the vaccine, suppressing of disease, development of suspicion in safety of the vac-cine and repeated outbreak. This cycle is shown in figure 3.2.6: (Chen & Hibbs, 1998, taken from Goldenberg, 2016).

Based on this, it may be concluded that the more abstract and distant from the public the disease is, the fear of consequences of vaccination is more present. This method of “teach-ing” the public, however, is very painful and includes unnecessary loss of human lives. So, many resources have been invested in identifying psychological barriers that obstruct com-munication of the messages “vaccines are safe” and “the benefits of vaccine overweigh the risks” to the public.

Figure 3.2.6 – The cycle disease-vaccination-anti-vaccination fears

IPre-vaccine

IIIncreasingcoverage

Disease

OutbreakVaccinationcoverage

IIILoss of

public trust

IVResumption of

public trust

Incid

ence

Time


3.2.6. Ignorance of the public, lack of “scientific literacy”The first, obvious assumption, was that the public was not informed enough about the ef-fects of vaccines or their adverse effects, and not competent enough to interpret the results of scientific studies. To communicate with the public, a few experts, mainly epidemiolo-gists, would emerge and would be perceived as the official representatives of the scientific community trying to debunk the misbeliefs associated with vaccine safety. The most prom-inent examples of this practice are Paul Offit, MD who was active in the USA, and Michael Fitzpatrick, active in Great Britain. They appeared in the media, wrote articles in magazines and instructions for doctors, as well as books about parenting and popular-science books with headlines such as “Deadly choices: How the anti-vaccine movement threatens us all (Offit 2011). Their strategy had both positive and negative aspects: negative impacts were merciless attacks on anti-vaccination ideas and their promoters (revealing the conflict of in-terests, shortcomings of the sample and inadequate measuring in case of Wakefield; point-ing out the incompetence of celebrities with no medical background who suggested avoid-ing of vaccination – for instance, a fitness guru and actress Jenny McCarthy); a positive effect was pointing to accumulated scientific proofs about vaccines’ safety.

The first step of this positive, corrective strategy was to identify the basic false beliefs about the harmfulness of MMR vaccines3 Gerber and Offit (Gerber & Offit, 2009) mention the three most widespread:

1. the connection between MMR vaccines and autism

2. the connection between Thiomersal and autism (a preservative with mercury used in vaccines with inactive viruses cause autism)

3. vaccines that “invade the system” (sensitive children’s organism is exposed to the unnecessarily large number of vaccines at a very early age, which triggers deteriora-tion of immunity system and a range of adverse effects)

Using empirical evidence from hundreds of cross-cultural epidemiological studies, as well as the data on exposing the child’s body to different challenges, far stronger than vaccines, that the body can cope with successfully, these authors conclude:

These epidemiological studies provide evidence that the assumption that vaccines invade the child’s immune system is unfounded and clearly prove that vaccines do not cause au-tism. Future studies on autism need to focus on other potential causes (Gerber & Offit, 2009, page 460)

The corrective strategy, therefore, assumes that the only reason for persisting vaccine hesitancy is the fact that the scared public cannot integrate robust scientific evidence into their image of the world. In the editorial article written by the experts of WHO (Clements & Ratzan, 2003), the media are partly blamed for this situation:

“Given that the media elaborated the safety of MMR vaccines, the public has, quite expect-edly, come to a conclusion that there is no smoke without fire; so there must be some truth in all the warnings… Non-professionals are not expected to discover shortcomings or incon-sistencies in arguments, to analyse the ratio of risks and gain or identify gaps in the present-ed pieces of evidence. (Clements & Ratzan, 2003, page 22) “

3 Most of the examples in the text will refer to MMR, given that its alleged connection with autism has provoked the latest wave of anti-vaccination skepticism, which was, in many countries, generalized to other compulsory vaccines.


Support of the public is, however, necessary to preserve public health. Instead of expect-ing passive acceptance of the arguments presented by the scientific community, the public needs to be included in the process of risk assessment. Additional confronting of the public with the conflict of interests or ignorance of promoters of anti-vaccination are the strategies that may be counterproductive. The leaders of anti-vaccination movement tend to be per-ceived as “lonely warriors against the system”, “brave people who speak the truth”, “indi-viduals fighting the pharmaceutical-mafia”, and scientific establishment as trying to hide the unpleasant truth (Habakus & Holland, 2013), while revealed connections between promot-ers of vaccination and producers of vaccines just make this belief stronger (Mercola, 2009).

Equally important, the message about vaccine safety does not reach its target audience as it does not address their sources of concern. Some experimental studies confirm that at-tempting to debunk erroneous beliefs with direct counterarguments may not produce the desired effect, but in fact may even provoke the counter effect (Bedford, 2014; Nyhan & Reifler, 2015). It is therefore important to treat equally both participants in the process of communication – both the health system and its users and rebuild trust between them. Since 2010, the London School of Hygiene and Tropical Medicine has launched a Global vaccine confidence project (http://www.vaccineconfidence.org). This project monitors glob-al confidence trends in vaccines and suggests measures for intensifying trust in vaccines.

3.2.7. Lack of trust in the health systemStudies suggest that the effect of anti-vaccination messages is mediated by the feeling of helplessness, disappointment and mistrust in the health system (Jolley & Douglas, 2014). The climate of general mistrust stimulated by sensational media reporting is especially sus-ceptible to spreading and strengthening different conspiracy theories. The cases when the public procurement system was not transparent and when the atmosphere of fear of inade-quate proportions was created, did not help to create a more positive attitude towards vac-cination, quite the contrary.

Studies show that there is a lack of trust in institutions among the citizens of Serbia; al-though healthcare and education are trusted the most, considerable portion of the popula-tion (42%) claim that they do not trust the health system (Figure 3.2.7).


Figure 3.2.7 – Trust in institutions, general population of Serbia, 2016 (source: Pointpulse)

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Sum ( Mostly have trust + Completely trust + Don't know )Sum ( Don’t have trust at all + Mostly do not have trust)

The lack of trust in institutions is related to the lack of trust in the intentions of politicians and policymakers, and mistrust in the official explanations of important or unexpected events commonly referred to as conspiracy theories. Conspiracy theories are a specific way of per-ceiving the world, and studies suggest that people who embrace one conspiracy theory will also embrace the others, very different in content (Goertzel, 1994; 2010). All these theories are based on the belief that the world is led by a few powerful people whose true motives are always hidden. Conspiracy theories should not be viewed as a problem per se, as they may even intensify transparency of communication with the public. The problem is, howev-er, that they are “resistant to arguments”, so any proof that opposes them is usually reject-ed as invalid, fabricated and also part of a conspiracy. On the other hand, such rigid belief system may lead to a range of inadequate behaviours, such as avoiding contact with health-care institutions and focusing on alternative medicine and self-healing. A study conducted in 2014 on representative sample of US citizens suggested that respondents who believed in three or more theories had their health checked more rarely, they visited the dentist more rarely, but it was more common for them to use herbal and vitamin supplements than re-spondents who did not believe in conspiracy theories (Table 3.2.3).


Table 3.2.4 – Health behaviours and belief in medical conspiracy theories (Oliver & Wood, 2014)

Respondents Who RegularlyEngage in the Behavior, % (N=1351)

No. of Medical Conspiracy Theories Agreed With

Behavior Total 0 1 or 2 ≥3

Take herbal suplements 20 13 22 35

Buy local/farm stand food 23 14 30 37

Prioritize organic food consumption 21 18 22 24

Take vitamins 57 54 61 58

Get annual phisical examination 45 48 46 37

Get influenz shot 35 39 36 25

Visit dentist 41 44 39 33

Use sunscreen 35 38 34 30

On representative sample of citizens of Serbia (Milošević-Đorđević & Žeželj, 2017), it has been detected that most people accept at least one conspiracy theory, and that average ac-ceptance of conspiracy theories is 7.5 on an 11-degree scale.

Lack of trust in the health system, belief in conspiracy theories and the feeling of disappoint-ment, result in stronger suspicion regarding health recommendations. Accepting vaccina-tion is, in that sense, especially sensitive, particularly because parents are to make a de-cision about another person – their child. We will try to explain this in the next chapter, i.e. to shed light on the psychological factors that make beliefs about vaccination so unstable.

3.2.8. The expected cognitive barriers to vaccinationWhen asked to accept vaccination, parents are actually asked to trust someone blindly – they are to expose their small and healthy child to a process that includes injecting an “un-known” substance which is supposed to protect the child from diseases that seem unlikely at that moment, and the consequences of which they have not witnessed. As long as vac-cination is not questioned, or as long as the norm is to accept vaccination, the coverage is big; but as soon as dissonant voices appear, or the question about risks and gain is asked, some parents decide not to vaccinate their children relatively quickly, and many more start to have doubts about vaccination of children (Leask, 2011).


I can see now how poorly informed I had been about vaccines… With my first child, when I was told by the paediatrician to do so, I took my child to receive a vaccine and that’s it. It was only here, in RR (parents’ internet forum) that I have heard that one vaccine integrates a few of them, and I have found out about this debate about links between vaccines and autism. It’s a pity that I don’t know anything about this, but this is it… I don’t know what I will do with my younger child.

Mother at Bebac forum portal

The cultural transmission theory (Miton & Mercier, 2015) assumes that it is easier and fast-er to communicate intuitive than counterintuitive beliefs among amateurs. For instance, although bloodletting or detoxication are proven to be inefficient, they keep appearing in different forms and they are used because they rely on an intuitive belief that elimina-tion of something from the body facilitates its recovery. Vaccination is, due to several rea-sons, counterintuitive: (a) we feel disgusted with pathogenic substances, irrespective of their amount – although body is injected with small doses of virus, disgust, as a reaction, persists, (b) we believe that active harming is more wrong morally than failing to do a good deed – in other words, that doing it is more dangerous than not doing it and (c) visibility of symptoms – it is more probable that we will detect adverse effects of vaccination than con-sequences of diseases, so it is more acceptable to expose your child to the risks of non-vac-cination than to vaccination.

Specific reasons: vulnerability of children, religious affiliation

All these barriers are stronger among parents of the so-called “vulnerable children” (prema-turely born, chronically ill) or parents committed to some ideology or belief (for instance a religious belief that directly forbids vaccination; myths about harmfulness of vaccination as a part of cultural folklore or verbal tradition – e.g. in some Roma communities in the east of Serbia).

Manipulating with fear – fear of vaccination or of disease?

Studies suggest that intimidating people with consequences of diseases is more efficient that debunking myths about vaccination (Horne, Powell, Hummel & Holyoak, 2015). This study uses an anecdotic example of a mother who regrets not having vaccinated her child who got measles with complications; followed by photos of children with measles, mumps and rubella; this message changed the attitudes of receivers, both parents and others, more than the message with evidence that proved that vaccines do not trigger autism (Figure 3.2.8).

In other, similar studies, it was also proven that busting myths of harmful effects of vac-cines – for instance the one claiming that flu vaccine can actually cause flu (Nyhan &Reifler, 2015), even when the receivers of this message are assured that the myth is untrue it actu-ally has no effect on their intention to be vaccinated.


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Figure 3.2.8 – Efficiency of using fear of diseases to manipulate the attitude towards vaccination(Horne et al., 2015)

Condition

Studies on the efficiency of causing fear, on the other hand, give no uniform results either. Evidence suggests that, for instance, smokers faced with terrifying health outcomes caused by smoking (for instance photos of damaged lungs) use different defence strategies: they process information selectively, they ignore it actively, rationalise portions of information (consider themselves an exception from the rule, alleviate outcomes, deny causality, talk of anecdotic counter-examples) (Ruiter et al., 2014). These strategies enable them to keep on with undesired behaviour, although being exposed to an aggressive campaign on negative effects of smoking.

It seems that, besides the need to assure people that a threat is strong, people also need to be assured that the offered solution is efficient in dealing with the threat. One meta-analysis (Witte & Allen, 2000) groups studies in four categories, related to the strength of the threat (i.e. whether the triggered fear is intensive or mild) and related to how effective or ineffective is the solution offered. The messages containing strong threat were most efficient, as well as those with an efficient and available solution.

When these findings are applied to vaccination, it seems that communication with the public requires activity on two fronts: assuring people that, on the one hand, vaccines are efficient and safe, and on the other, that the diseases are real. The situation with vaccination is spe-cific because there are two sources of fear: one of the consequences of vaccines, and the other of the consequences of diseases. When communicating with the public, it is import-ant to accept the fact that both behaviours (vaccinating and non-vaccinating) carry a certain amount of risk, but it is also important to insist on the DEGREE of risk which is different: al-though no vaccine is 100% efficient or 100% safe from side effects, the risks of being sick are far immeasurably more serious.

The public is focused on the presence or absence of risk, rather than on assessing the rel-ative risk of some specific health behaviour.” (Clements & Ratzan, 2003, page 22.)


I also had a dilemma because it is simply not possible to ignore all those stories (and I am not medically educated), but after talking to our paediatrician, we decided to wait for the autumn and vaccinate the child then. Honestly, I am more afraid of diseases that might be life-threatening, than of the possibility that my child might become autistic.

Statement of a mother from ANA portal forum

3.2.9. What are the arguments of anti-vaccination movement?Anti-vaccination movement uses different communication tactics to convince the public that vaccines are unsafe, or at least to raise doubts about this issue. These tactics are system-atized in four basic groups (Table 2.1.7): two refer to the treatment and interpretation of scientific evidence, and the remaining two to the treatment of people who express differ-ent opinions in public discussion. (a) Scientific studies are chosen and interpreted so that they support the anti-vaccination agenda. (b) The arguments offered as support to the idea of harmfulness of vaccines keep changing (for instance it was claimed that MMR vaccine caused autism, but the study conducted by Wakefield et al. was withdrawn4; the preserva-tive Thiomersal that contains mercury was blamed for causing autism at that time after vac-cines with Thiomersal were withdrawn from the market because of the pressure of the pub-lic, and there was no decrease in the number of diagnosed autistic children, the most re-cent papers underline the toxicity of aluminium). (c) Online forums and blogs about vaccine safety exclude members whose opinion opposes the predominant opinion – the one against the vaccination. (d) People with different opinion are openly threatened or filed complaints against (this is especially present in the USA, where “the war over vaccines” has been rag-ing the longest and where the opposing sides are highly antagonized).

Analyses of statements by prominent figures of the anti-vaccination movement in the media and communication of known and unknown supporters in virtual space show that there is actually a limited number of typical phrases used as arguments in discussions; some become circular, other offer false dichotomies (dangerous diseases or dangerous vaccines), and the third is impossible to deny (continuous listing of new potentially toxic ingredients of vaccines) (Table 3.2.6).

4 Wakefield remains a hero of the anti-vaccination movement; some even go so far as to claim that, for them, Andrew Wakefield is “Nelson Mandela and Jesus Christ embodied in one person” (Dominus, 2011)

Table 3.2.5 – Systematization of tactics used by the anti-vaccination movement in public communication

Adapted from Kata, 2012.

Communication tactics Description

Biased interpretation of scientific evidence

Rejecting evidence that does not back up the dangers of vaccination; accepting methodologically doubtful and unofficial studies that support anti-vaccination agenda

Change of central hypothesis

Continuously offering new theories about harmfulness of vaccines; when they run out of evidence, they change the “target”

Censorship Rejecting a different opinion; excluding criticism from communication

Attacking people with different opinions Direct attack through personal insults or through legal channels


5

5 The best illustration of such false dichotomy is the statement of Jenny McCarthy “Let us choose between autism and measles and we will all form a line for the bloody measles!” (Chicago Sunday Times, April 2014)

Typical statement Description

I don’t oppose vaccines, I just support safe vaccines.

Insisting on unsafety of currently used vaccines, not opposing vaccines in general

Vaccines are toxic. Specifying potentially toxic ingredients of vaccines, without information about quantity of mechanisms of their action

Vaccines must be 100% safe. Given that medical officials can’t guarantee 100% safety of vaccines, it means that they are dangerous

You can’t prove that vaccines are safe.

Insisting that the scientific community must provide evidence that vaccines don’t trigger specific diseases, instead of asking

the anti-vaccination community to provide evidence that they do (analogous to proving innocent in a court trial)

Vaccines haven’t saved us.

Attributing eradication of diseases to other factors (e.g. awareness of hygiene), and not vaccination. A tool often used are figures with

the number of the dead of infectious diseases, which show that the decreasing trend started before vaccines were introduced, but without presenting figures with the incidence of diseases, which clearly show enormous reduction upon introduction of vaccines.

Vaccines are not natural. Insisting that everything natural is better than “unnatural”; e.g. natural strengthening of immunity is better than artificial with vaccination

We choose between diseases and adverse effects of vaccination.

Presenting a choice as a false dichotomy between being sick and suffering the effects of vaccination5, without the option “vaccination

without adverse effects”, which is actually the most common.

Galileo was tried too.Making parallels between scientists who were tried because

they questioned valid scientific paradigms and anti-vaccination ideas (current controversial ideas will be accepted in time)

Science makes mistakes. Quoting documented errors in science and revised scientific beliefs

There are too many of us to be wrong.

Specifying the number of opponents of vaccination as an argument for validity of statements

You are paid by the pharmaceutical industry.

Accusing people who don’t share this opinion of conflict of interests, or of collaboration with pharmaceutical industry

I don’t believe in coincidences.

Rejecting the possibility that some chronic diseases can occur spontaneously or be provoked by factors other than vaccines that preceded them (“preceded” is a very flexible

time period – from a few hours to a few months)

I am an expert for my own child. Insisting that parents are undeniable and only experts for the health of their children; rejecting medical authorities

Table 3.2.6 – Typical phrases and arguments used by the anti-vaccination movement

Source: Kata, 2012.


The same arguments are used in the internet space in Serbian, and other ex-Yugoslav lan-guages. The public figure of anti-vaccination movement in the region is Slađana Velkov, who presents herself as a doctor of medicine. Her Facebook group has more than 30 000 followers. Although some kind of waiver of legal responsibility is on the cover page, it pro-vides direct advice on how to avoid vaccination, as well as terrifying information that should support such decision:

“Everyone who produces, prescribes and injects vaccines, knowing that they are very dangerous, participates in a mass murder. Vaccines have nothing to do with eradicating infectious diseases, and the proof can be found in these official maps where we can clearly see that... all vaccines were implemented after eradicating 90% of diseases (link). Some diseases disappeared without vaccines, such as tuberculosis in America. What eradicated them is hygiene and better nutrition.

If it weren’t for vaccines, perhaps we would all be Nikola Tesla, perhaps we would live for 130-140 years as the Hunza people who aren’t vaccinated, perhaps our children wouldn’t be sick while receiving vaccines...

Children do not die of vaccines in a few hours, which I know very well as a doctor, but a slow death is a death, too. Some poisons kill instantly, others very slowly. Top world scientists have already discussed vaccines and proven their harmfulness and no benefits, and one of them is American neurosurgeon Dr Russell Blaylock who has proven all this in his studies. It was hard for me to believe this myself and to accept that the lie we live in is so deep, until one day my mother-in-law got sick after receiving the seasonal flu vaccine and died after a year and a half.”

(Slađana Velkov, public announcement on Facebook group “Dr Slađana Velkov”, discussion about vaccination – non-edited; added italics)

https://www.facebook.com/notes/dr-sladjana-velkov/diskusija-o-vakcinaciji-i-kako-je-izbeci-pisite-iskustva-i-predloge/305072706179969

Media. Numerous evidence suggests that the atmosphere created by the media has an influence on the opinion about vaccination. For example, one study conducted in Wales shows that immunization coverage was significantly smaller in the area distributing news-papers that actively supported a campaign against MMR vaccines, compared with the rest of the country (Mason & Donelly, 2000). A Swedish study on parents who avoided or post-poned to vaccinate their children shows that more than 80% mentioned media as the main source of information (Dannetun et al., 2005). The results of a big international study con-ducted in 1998 show that immunization coverage is smaller, and incidence of pertussis big-ger in the countries whose media had anti-vaccination campaigns, compared with other countries (Gangarosa et al., 1998).

The Internet has made healthcare information generally available; Web 2.0 (the second stage of internet development characterised by more extensive interactivity and user-gen-erated content) has enabled laypersons, patients and the interested public to express their opinions, exchange experiences and advise each other. Studies show that 80% of Internet users search for information about health online; 16% of this group seeks information about vaccination, a 70% of them state that the information they found influenced the decisions




they made. Judging by some studies, the internet is equally, if not even a more important source of information about health than medical workers (The Pew Internet & American Life project, 2011). Active search for information is expected the behaviour of patients within the new treatment paradigm, in which a patient is considered an active and empowered partici-pant in healthcare services. The new paradigm means that healthcare is personalized, and communication between a patient and an expert is a two-way street. However, information available on the internet are not reviewed by the professional public. This means that true and false information is equal, that science and pseudoscience are not clearly separated, that experts and amateurs are given equal space and have potentially equal influence. To decide what sources are reliable, a user must be both media and scientifically literate, which a large part of the population is not. Additionally, internet groups usually bring together peo-ple who share similar views, so they create the illusion that there are a lot of like-minded people. That way, the users strengthen each other’s views in a so-called “echo chamber” (Kata 2012).

An Internet search on vaccination with keywords in English directs users mainly to an-ti-vaccination websites; Google search with keywords in Serbian (“vaccine safety” or “MMR vaccine”), gives more than half of anti-vaccination contents on the first page (Appendix 1, Results of internet search in Serbian).

Social networks are used as a platform for mobilization against vaccination, for instance, the Civil Association for non-mandatory vaccination. Here is an example of such initiative (https://www.facebook.com/notes/sladjana-velkov/gradjanska-inicijativa-za-neobaveznu-vaccination/10152878749584974/):

Dear friends,

We are planning to organise a conference of all associations that advocate voluntary vaccination in south-eastern countries where vaccination is compulsory, and we plan to invite all doctors, scientists and lawyers who support voluntary vaccination.

It is necessary to found an association called Civil initiative for voluntary vaccination that would be engaged in this activity only. If there is anyone interested in Serbia, Macedonia, Montenegro and in other countries, please let us know in the comments. Furthermore, if you find contacts of similar associations in the countries in the region, inform us about that, please. The initiative for this conference has started from Slovenia.

With love, Slađana

As the outcome of this invitation, several organizations with the suggested name were es-tablished in the Western Balkan region. These organizations have coordinated a whole chain of protests against compulsory vaccination in many places in Serbia, Croatia and Slovenia and took it to media.

Legal advice about how to avoid vaccination can also be found online; there are also spe-cialized YouTube channels that collect, translate/adapt or even produce documentaries, media coverage or video clips from conferences dedicated to the fight against vaccination (the list of Internet sources with these contents is given in Appendix 2).


The Internet can, however, be used for promotion of vaccination and as a tool in assisting parents when making decisions. Here are some examples of scientifically validated good practices.

3.2.10. Examples of good practice in vaccine-related communication

Tools that assist decision-making

The Australian Ministry of Health supports an Internet tool designed to assist parents to make informed decisions about vaccination of children (http://www.ncirs.edu.au/consum-er-resources/mmr-decision-aid/ ). This tool was introduced in 2006, and it is regularly mod-ernised and updated with new information. It is specified as an example of good practice because it is guided by the principles of fair and responsible communication with the public. The user is offered a wide range of options (Picture 3.2.1):

The users are informed about the symptoms of vaccine-preventable diseases, frequently asked questions are answered, the risks of vaccination and non-vaccination are compared, the reasons FOR and AGAINST are listed, the users are informed about the percentage of parents who opt for vaccination (between 80% and 95% in most countries), they are in-formed about the options and directed to original scientific sources for further information. Positive effects of this tool have been validated in several studies and in several English-speaking countries (Shourie et al., 2013; Walace, Leask, & Trevena, 2006).

Picture 3.2.1 – Topics available to users, tools for assisting the decision-making process about MMR

MMR decision aid + IntroductionSymptoms of measles,mumps and rubellaFAQ1 - The vaccineFAQ2 - The vaccine safetyFAQ3 - Vaccine impactComparing risks - MeaslesComparing risks - MumpsComparing risks - RubellaMaking a decisionReasons FORReasons for NOTOptionsLinksReferences

NCIRS Position Statement onHPV Vaccination

No Jab No Play, No Jab NoPay Policies


Brochures for conversations aimed at assisting those who are vaccine -hesitant

Some associations of medical workers or parents aiming to increase coverage of vaccina-tion and to debunk myths of the harmfulness of vaccines, publish manuals that facilitate communication with close people in their surroundings, who doubt the efficiency of vac-cines or who are hesitant about vaccination. (http://www.voicesforvaccines.org/content/up-loads/2016/02/Vax-Hesitant-Loved-Ones-Toolkit.pdf).

Monitoring public mood in real time

A group of Canadian researchers (Seeman, Ing & Rizo, 2010) developed a software tool that enabled them to monitor internet communication about vaccination against H1N1 vi-rus: the keywords in communication, the fastest-spreading and most-shared-on-social-net-works information, popularity trends of websites that support and oppose vaccination. Since processing was automatic, researchers could monitor the dynamics of reactions of the au-dience in real time, and react with recommendations in a timely manner. They have also developed a chat application through which people could talk to medical staff trained for communication with the public (Picture 3.2.2).

These examples clearly show that the internet can be a tool for disseminating pseudoscien-tific and unconfirmed contents but in the same manner, it can equally be used to facilitate spreading of information, to remove doubts, provide social support and empower parents in their decision-making process, as well as quickly test the efficiency of different forms of communication with the public.

Picture 3.2.2 – Chat application developed for talking about the H1N1 vaccine

49Overview of Methodology

4 Overview of methodology

In order to fulfil all of the above mentioned objectives, this research included several methods of data collection, and in Table 4.1. there is a brief overview of each of them.

6

6 More detailed about focus groups discussions and guidelines for them are provided in Appendixes 4 and 6.

Table 4.1 – Overview of methodology

Type Short description

1

Des

k re

sear

ch

■ Comprehensive analysis of the existing documents, studies, reports

■ The aim of this part of the research was to provide a general wider context of the current situation in Serbia concerning immunization and related knowledge, attitudes and practices. At the same time this meant a review of published and "grey" literature on the topic of immunization, as well as a review of literature, data, reports and research specific to Serbia only.

2

Qua

litat

ive

rese

arch

– F

ocus

gro

up d

iscu

ssio

ns w

ith

pare

nts

of c

hild

ren

aged

0 to

7 y

ears

6

This phase of qualitative research was conducted in four municipalities in different regions of Serbia –Belgrade, Novi Sad, Požarevac and Niš.A total of 20 FGDs were realised with parents of children aged from 0 to 7 years, and the following structure was followed:

1. General population – parents from urban settlements who vaccinate their children –1 group in each municipality (total 4)

2. General population – parents from urban settlements who do not vaccinate their children– 1 group in each municipality (total 4)

3. General population – parents from rural settlements who vaccinate their children– 1 group in each municipality (total 4)

4. General population – parents from rural settlements who don’t vaccinate their children– 1 group in each municipality (total 4)

5. Mothers living in Roma settlements – 1 group per municipality, except municipalities in which there is not a sufficient number of Roma (total 3)

6. Fathers living in Roma settlements – 1 group in Niš (total 1)

Within general population, the groups were made up of mothers and fathers. Focus groups with parents from Roma communities consisted of both those who vaccinated their children, and those who did not vaccinate their child on time, and / or those with negative attitudes towards vaccination.

Representatives of parents who do not vaccinate their children were selected among those who refused to give their child at least one compulsory vaccine, or those who did not vaccinate their child in time, and/or those who have negative attitudes towards


7 8 9

4.1. Qualitative research with parents of children aged from 0 to 7 yearsFocus group discussions are a qualitative research method aimed at deeper understanding of the phenomenon of research interests. For the focus group discussion it is characteris-tic that their realization tends to gain deep insight and understanding of opinions, attitudes, feelings and knowledge of the participants in these groups. Their realization enables col-lection of comprehensive information on the occurrence of interest over a short period of time, however, the results obtained cannot be generalized – but they should be observed

7 More detailed about in-depth interviews and guidelines for them are provided in Appendixes 3 and 6.8 Realisation of one in-depth interview with representatives of anti-vaccination lobby was planned, but this interview was not realised because of non-response of respondent until finalisation of this research.9 More detailed about methodology design of the quantitative survey and questionnaire are provided in Appendixes 5 and 6.

3

Qua

litat

ive

rese

arch

– In

-dep

th in

terv

iew

s

with

hea

lth w

orke

rs a

nd k

ey in

form

ants

7

A total of 24 interviews were realised with the following structure:I Medical workers–16 interviews in total

■ Paediatricians from Health Centres – 1 interview per municipality (total 4)

■ Roma mediators – 1 interview per municipality (total 4)

■ Paediatric nurses – 1 interview per municipality (total 4)

■ Visiting nurses – 1 interview per municipality, (total 4)II Key informants – 8 interviews in total8

■ Representative of Health Ministry – 1 interview

■ Representative of the Institute for Public Health „Dr Milan Jovanović Batut“– 1 interview

■ Representatives of Institute for Public Health Belgrade, Novi Sad and Kraljevo – 3 interviews

■ Representative of League for Immunisation – 1 interview

■ Representative of the Association of Parents – 1 interview

■ Representative of the Association of Paediatricians – 1 interviewThe main aim of in-depth interviews was to get the perspective of medical professionals on parental attitudes, knowledge and practices related to immunization as well as to get their assessment of some key aspects of the immunization process and aspects related to legislation, vaccine supply, communication, role of health system and institutions etc. It was also to get the “big picture” about immunization in Serbia which would help to contextualize findings collected from parents.

4

Qua

ntita

tive

KAPB

su

rvey

on

pare

nts

(mot

hers

) of c

hild

ren

aged

from

chi

ldre

n ag

ed

from

0 to

7 y

ears

9 ■ Survey on representative sample of parents (mothers) of children aged from 0 to 7 years in 824 households, which makes possible analysis of data according to categories of regions, type of settlement (urban and other), age, education and income;

■ Mixed mode – survey „face-to-face“ (CAPI – Computer Assisted Personal Interviewing) and CAWI (Computer Assisted Web Interviewing). 635 CAPI interviews and 189 CAWI interviews.


as attitudes which are typical for representatives of population participating in focus groups. Focus groups are organized with the presence of moderator (facilitator) who facil-itates and directs communication of participants, and in this research, trained moderators were researchers with significant experience in facilitation of social-psychological research on various topics. Guidelines for focus group discussions weren’t pre-tested, but their im-plementation in Belgrade was done before other cities. As their organization and implemen-tation went without any problems, no further changes were needed for the guideline and recruitment criteria.

Average duration of focus groups was 120 minutes, and each group had 8 participants. Participants in groups with general population were combined by gender, age and level of education. Practice in qualitative research is to recruit for such discussion the respondents who have minimum secondary education, because experience has shown that they have greater fluency and show generally greater readiness to openly express their opinions and attitudes before other people. For the focus group with representatives of the Roma popu-lation, the education variable was not taken into account when recruiting the participants. Location of focus groups was chosen in cooperation with UNICEF Serbia. Belgrade, Novi Sad and Niš were selected as the biggest cities in Republic of Serbia, while Požarevac was selected because of previous data which indicate lower level of vaccination coverage in this town. The structure of the focus groups in this research is shown in the table 4.1.1.

10

10 Education of parents from Roma population was not taken as a criterion for selection of participants because, for the purposes of this research we needed typical representatives of Roma population from Roma settlements who often had only primary or secondary educa-tion. Therefore, to avoid their feeling of being discriminated, education was not taken as a criterion for recruitment.

Target group – Parents of

children aged 0-7 years

Type of settlement Location

Attitude towards

vaccination

Level of parents’

education Age of

children

General population . mothers and fathers Urban

Belgrade, Novi Sad, Niš,

PožarevacPositive

Secondary and university

education0-7

General population – mothers and fathers Urban


PožarevacNegative


education0-7

General population – mothers and fathers Rural


PožarevacPositive


education0-7

General population – mothers and fathers Rural


PožarevacNegative


education0-7

Roma population – mothers

Roma settlement

Belgrade, Novi Sad, Požarevac

Positive + Negative NA10 0-7

Roma population - fathers

Roma settlement Niš Positive +

Negative NA 0-7

Table 4.1.1 – Structure of focus groups:


4.2. Qualitative research with health workers and key informantsIn-depth interviews are also a method of qualitative research which is conducted with the same aim as focus group discussions – for deeper understanding of the studied phenom-ena. In contrast to focus group discussions, the in-depth interviews are conducted "one-on-one" with the respondent, and are suitable especially for research on key informants or members of vulnerable groups. In-depth interviews are semi-structured formats, where topics and key issues are clearly defined in advance, but at the same time it is possible to ask new, additional questions if conversational flow demands it. Also, in in-depth interviews open-ended questions are dominant such as “how” or “why” to give the interviewer a free-dom to answer questions using his or her own words. However, similar to FGDs, the results obtained from the in-depth interviews cannot be generalized to population. The selection of key informants was performed together with UNICEF Serbia, which provided the list of re-spondents and their contact data, while the selection of healthcare sector representatives in four towns was performed by the Ipsos Strategic Marketing Serbia recruitment team. Moderation was also done by high experienced moderator. Also, guidelines for qualitative survey with key informants weren’t pretested. On the other hand, as for the focus groups with parents, qualitative survey with health workers was first done in Belgrade, and as its implementation has gone without any difficulties, the same guideline was used in other cit-ies too. The respondents from healthcare sector were defined by their profession and their active employment in paediatric ward in primary health centres. The initial idea of the ToR was to conduct a quantitative survey on a larger sample of healthcare workers, but due to a lack of agreement with the Ministry of Health, this idea was dropped and a qualitative re-search on a small sample of health workers and key informants part was conducted.

In this part of the research in-depth interviews were conducted with key informants and rep-resentatives of health sector in previously mentioned 4 municipalities: Belgrade, Niš, Novi Sad and Požarevac. Detailed structure is represented in Appendix 6


4.3. Quantitative survey with parents/mothers of children aged from 0 to 7 yearsThe survey on mothers/primary caretakers of children age 0 to 7 years was realized through 849 interviews. Out of the total number of them, 635 were „face-to-face “, conducted in re-spondents’ households, and 189 were conducted through Ipsos CAWI panel. CAWI is a data collection mode developed for respondents who primarily use modern communication means as the basic mean of communication, instead of traditional, such as CATI, CAPI or PAPI. PANEL is the IPSOS database of respondents, which includes all respondents who have participated in previous Ipsos studies – CAPI, CATI or PAPI and which gave consent to be included in this database and contacted for various researches that Ipsos is doing on the annual level. IPSOS Panel has been available in Serbia since 2013 – it currently has 15,500 respondents. Finally, Roma parents were also covered by the survey – 211 parents/mothers from Roma settlements. Detailed overview of each of these segments is given in Appendix 6.

Survey was pretested in pilot research to examine its length and its understandability. A to-tal of 18 face-to-face interviews were conducted (10 with mothers from general population and 8 with mothers from Roma population) with mixed age, education background and from different regions. After pre-test of the survey, questionnaires were finalized in close collab-oration with UNICEF.

The household part of the survey on mothers/primary caregivers of children aged from 0 to 7 years from general population was conducted on two-stage stratified random nation-ally representative sample. The sample design is based on the data from 2011 Census of Population and estimates of Ipsos Strategic Marketing for 2013. Stratification was per-formed based on region (Belgrade, Vojvodina, West Serbia, Sumadija, East Serbia, South Serbia) and type of settlement (urban and rural), and sample allocation was performed to be proportional to size of stratum – number of children aged 0 to 7 years within each stra-tum. The purpose of this sample allocation was to optimize the sample plan and to minimize sample error. In total, 635 interviews were conducted. The decision about sample size was made with UNICEF team, and it represented the optimal sample size when resources were considered. Ipsos Strategic Marketing proposed the sample size of 1000 respondents on F2F survey that is more optimal having in mind sample error and sensitivity of the subject of the research. This was overcome including the respondents from Ipsos Panel, which gave in total 824 respondents. Our proposal for future researches is to conduct F2F component on a bigger sample size.

In combination with 635 respondents from the face-to-face method survey, the usage of these two methods of data collection gave the mixed method of data collection for minimiz-ing the bias of non-response rate for some subcategories of respondents. There are two main designs for mixing modes of data collection: concurrent and sequential mixed-method designs. In a concurrent mixed method design, two or more modes are implemented within a certain time. For example, respondents could be offered a choice of data collection meth-od. In a sequential design, different modes are implemented in sequential order during the data collection period. For example, non-respondents to the first data collection method could be followed up using a different data collection method. In this research, we used se-quential design: for CAWI methodology we selected a sample of respondents from subcat-egories which were missing on the face-to-face survey. Mixed-model designs are used very


frequently to minimize non-response bias of particular groups. Previous researches have shown that dual sample frame is useful when the amount of under-coverage from using a single frame is substantially improved by the introduction of a second frame. One relevant example of how response rate for modes may differ by population group is that of respon-dent age; there is some evidence that, compared with older respondents, younger people are more likely to state a preference for web over postal surveys 11. Previous surveys in Serbia on large samples show that there is higher non-response rate among younger pop-ulation, population from urban settlements and employed population. Exactly these sub-categories were the ones which were covered by CAWI method of data collection. CAWI method was used once CAPI survey was done to supplement for all those groups of re-spondents with bias during CAPI interviewing. However, it is important to emphasize that selection of additional sample for CAWI method was done in a way to secure the national representativeness of the overall sample reached through both CAPI and CAWI. So, no ad-ditional analyses were applied on this population only, but the obtained data were weighted and interpreted together with the data collected through the household face-to-face CAPI.

The online survey with mothers / primary caregivers of children aged 0 to 7 years in the general population on a sample of 189 respondents aimed at reducing the impact of non-re-sponse of certain categories of population. In other words, online survey includes those categories that are prone to non-response or are more difficult to access with face-to-face survey method. Previous surveys conducted among general population indicate that non-re-sponse rate is higher among younger categories of population, urban population and em-ployed population. Bearing in mind these data, the online survey included mothers / primary caregivers of children aged 0 to 7 years in urban areas as well as those age groups of moth-ers / primary caregivers who showed more non-response in field survey.

As mentioned before, official Census data for 2011 and population estimations of Ipsos Strategic Marketing for 2013 were used for allocation of the sample size, and sample alloca-tion was performed proportional to size of the stratum. In other words, the allocated number of sampling points in each stratum is proportional to size of the stratum. For online sample, quotas by age and region were used to fulfil the gaps from F2F component. In total, sample for general population consisted of:

■ Females (90%) and men (10%)12

■ Respondents aged up to 30y. (45%) and respondents aged 30 and above (55%)

■ Respondents with primary education or less (12%), with secondary education (59%) and higher education (29%)

■ Respondents from urban parts of the country (64%) and respondents from rural parts of the country (36%)

■ Respondents from Belgrade region (24%), from Vojvodina (26%) and from Central Serbia (50%)13

11 Mixing Modes within a Social Survey: Opportunities and constraints for the National Survey for Wales, National Center for Social Research, Wales, 2012.12 Little participation of male respondents is expected since questionnaire was applied to primary caretaker, which is most often the mother. Due to small sample size of the male respondents, statistical analysis on this population and comparison between males and females can’t be done.13 In analysis and cross-tabulations in this research also used other sociodemographic variables like employment status and financial situation of the household.


Calculation of the sample size for general population was done following strong theoretical and empirical principles. The following formulas have been used in order to calculate how many respondents should be included in the sample, so that we can test one proportion, concerning whether a proportion, p, is equal to a reference value, p0. Therefore, Null and Alternative hypotheses are:

H0:p=p0

H1:p≠p0 Formulas which are used for sample size estimation and power are:14

n=p(1−p)(z1−α/2+z1−βp−p0)21−β=Φ(z−z1−α/2)+Φ(−z−z1−α/2),z=p−p0p(1−p)n−−−−−√

where

n is sample size

p0 is the comparison value

Φ is the standard Normal distribution function

Φ−1 is the standard Normal quantile function

α is Type I error

β is Type II error, meaning 1−β is power

Including these formulas and R code15, we concluded that we needed at least 397 respon-dents in each proportion in order to be able to make statistical conclusions with the 95% confidence interval, and the power is 0.80. Design effect for this study was 1.07.

14 Chow S, Shao J, Wang H. 2008. Sample Size Calculations in Clinical Research. 2nd Ed. Chapman & Hall/CRC Biostatistics Series. page 85.15 R code: p=0.5

p0=0.3

alpha=0.05

beta=0.20

(n=p*(1-p)*((qnorm(1-alpha/2)+qnorm(1-beta))/(p-p0))^2)

ceiling(n) # 50

z=(p-p0)/sqrt(p*(1-p)/n)

(Power=pnorm(z-qnorm(1-alpha/2))+pnorm(-z-qnorm(1-alpha/2)))


Survey on mothers/primary caregivers of children aged from 0 to 7 years from Roma pop-ulation was also based on 2011 Census of Population and estimations of Ipsos Strategic Marketing for 2013. The sampling procedure aimed to create a sample representative of the population in Roma settlements. Roma settlements are defined as settlements in which the share of Roma in the total population is more than 40%. For sample size of this part of the study, budget limitations were the main criterion for calculation of it. Regarding the sam-pling for general population, region and type of the settlement were used for stratification of the sample in order for each stratum to represents the entire population of Roma in Serbia in that stratum. In total, sample for Roma population consisted of:

■ Female (99%) and male (1%)16

■ Respondents age was up to 30 years (73%) and 30 years and above (27%)

■ Respondents with primary education or less (91%), with secondary education (9%) and none with higher education17

■ Respondents from urban parts of the country (73%) and respondents from rural parts of the country (27%)

■ Respondents from Belgrade region (18%), Vojvodina (15%) and Central Serbia (67%)18

With weighting procedure, the differences between the samples and populations were min-imized and it was guaranteed that data obtained on the samples represent the entire popu-lation. In line with that, results were reported not only on total population, but also on these defined subsamples (where size of the subsample was appropriated, N<25).19 Also, weight-ing procedures serve to minimize the influence of the inherent imbalances or biases that interviews and other data collection may have created. Here, it also must be noted that be-fore the weighting two steps were conducted in order to maximize the quality of the obtained data – fieldwork training and fieldwork control and monitoring.

Fieldwork training was held before the main fieldwork for all interviewers that were work-ing in the field. Training was held both by Ipsos and UNICEF representatives. This training covered all topics that were important for standardization of the interview work: description of the project, description of the sampling, random route, selection of the respondent and questionnaire administration.

Moreover, to ensure quality of data and apply unique methodology, data collecting process was standardized. This was enabled by:

■ developing a guideline for survey preparation and organization

■ developing an appropriate methodological guideline for data collection (filling in the questionnaires), a guideline for sampling the households in the field

■ supervision of the interviewing process

16 As for the survey for general population, little participation of the man is expected since questionnaire was applied to primary caretaker which is most often the mother. Due to small sample size of the man, statistical analysis on this population and comparison between them and females can’t be done.17 In analysis on Roma population will not be reported for the respondents with secondary education due to small sample size.18 In analysis in this research and crosstabulations are also used other sociodemographic variables like employment status and financial situation of the household.19 More detailed about the weighting procedure is explained in Appendix 6.


■ close cooperation and daily communication between supervisors and their interviewer

■ verification of collected data on daily basis, since interviewers are obliged to up-load completed questionnaires data and diary data to central team every day during the fieldwork

■ data processing

ISM team performed fieldwork control by back checking in direct contact with respondent and telephone control on 20% of the interviews conducted. Each interviewer was checked for at least one respondent they visited.

The following aspects of interviewers' work were checked:

■ The fact that the interview has taken place

■ Proper application of the sampling plan in selecting respondents

■ Approximate duration of the interview

■ Proper administration of sections of the questionnaire

■ Interviewers' general adherence to professional standards (did the interviewer properly behave, call back and follow all standard procedure).


4.4. Chronology of quantitative and qualitative design & project phasesThe research methodology was designed in a sequential way, meaning that each phase influenced the following one.

In the quantitative research, frequencies and means were used for data analysis. As for other complex statistical analysis, correlations, multiple regressions and chi square were also used.

For the qualitative part of the research, audio and video records of the FGDs and IDIs were transcribed, and the transcripts were used as the source of data. The analyses were focused on each of the topics included in the guidelines, but are also on their connections. Whenever possible, the responses, i.e. opinions, attitudes and experiences with regards to particular topics, were classified into homogenous groups.

Type of data collection How they were used to inform the outputs

Literature review

Desk analysis

Structuring the guidelines for FGD

Structuring the guidelines for in-depth interview

Guidelines for quantitative survey

Qualitative research phaseGuidelines for quantitative survey

Recommendations and policy brief

Quantitative survey phase Recommendations and policy brief

Table 4.1.2 – How different research phases were used to frame the following one

Focus groups with pro and anti-vaccinal parents,from general population and Roma

Quantitative survey with parents from generalpopulation and with Roma parents

In depth interviews with key information

Literature review

59Research Ethics

5 Research Ethics

The entire research, including the methods of data collection as well as the instruments, were previously approved by the UNICEF Ethics Committee. The work on this research is carried out in such a way that it fully respects UNICEF ethical standards.

Thus, this research did not in any way cause pain, suffering or harm to parents of children aged 0 to 7 years who participated in this research. On the contrary, the participants in this research were exclusively adult citizens of Serbia (18+), that is, parents who voluntarily agreed to participate. Also, during the qualitative phase, no harm was done to stakeholders and key informants who were part of this study.

Quantitative research respondents did not receive any monetary compensation for their participation, while participants in the qualitative research received vouchers for one of the retail chains in Serbia.

Due to the nature of this research, the interviewers who were a part of this research had special training, which, besides the topics related to research procedures, also included the following components:

■ Presentation of Client

■ Topics related to immunisation, with special focus on the existing official data about immunisation in Serbia

■ Detailed study of the questionnaire

After the training, the interviewers received a written protocol, intended to be a reminder during fieldwork.

Besides that, the realised research guaranteed full anonymity, confidentiality and privacy of all respondents. All participants were informed that the research was anonymous, and that their answers would be interpreted in cumulative form only, together with the answers of other respondents.

Before the beginning of the quantitative survey, respondents were informed that they would be asked a series of demographic questions involving personal data, such as: name, address of residence, phone number, etc., but it was guaranteed to them that these data would not be used by or forwarded to anyone else. Respondents were informed that the only purpose of collecting these data was telephone control of interviewers’ work, and only after receiving respondent’s approval, the interview could started. Finally, respon-dents were informed about average duration of the interview, that is, they were told that the interview would take about 45 minutes.


Respondents were also informed about potential risks and benefits that may arise as a result of participating in the research. After their verbal consent (respondents’ written con-sent was not needed because the research was conducted on adult citizens of Serbia, as well as because it would require further search for personal information), respondents started the interview. Information about the survey was provided at the beginning of the survey, in a cover letter left in each sampled household. The letter contained basic infor-mation about UNICEF as the entity that commissioned the research, about the very re-search and its aims (with clearly stated information on when they, as participants, would be able to obtain information about the results of the research), as well as basic informa-tion about IPSOS.

Additional efforts have been made to ensure anonymity, privacy and confidentiality of the interviewing process itself. Namely, whenever possible, the interviewer did the inter-view in an isolated room within the household, without other members of the household present, in order to minimize the influence of others on the responses. In the households where there were no conditions for such interview, it was conducted in the presence of others, but their influence was controlled.

All questions in the interview were formulated in such a way to avoid doing harm (physical or psychological) to respondents, therefore, not a single incident was registered.

As mentioned before, CAPI method was used for data collection in the quantitative part of the research. CAPI method enables direct entry of responses in the database. For data collection, IPSOS used SM-S programme (developed by ISM). SM-S programme is pro-tected with a code, so data on CAPI devices used for this project were coded. Data bas-es were stored on ISM server, which is also protected with a code, and only the research team who worked on this project had access to this code. After control of the interview-ers, all personal data were removed from database, in order to protect anonymity of re-spondents. For respondents who were a part of online survey, all described procedures are the same.

During the selection of respondents, human rights were fully respected. This means that all citizens of Serbia (all parents/caretakers of children aged 0 to 7) had equal chance to be part of the survey regardless of their socio-economic background or any other charac-teristic, such as ethnicity, nationality, gender, age or disability. For example, this means that if randomly selected respondent is a member of some minority group, he wasn’t ex-cluded from this research. However, due to the fact that part of the study was only with Roma population, parents/caretakers from Roma population were intentionally chosen – in other words, Ipsos interviewers went to Roma communities to look for Roma parents of children aged 0 to 7. As for the qualitative component of this research, all respondents were informed about the research objectives, as well as that the research was commis-sioned by UNICEF. Respondents were also informed that their participation would be anonymous, that their personal data wouldn’t be revealed in the report, but that the dis-cussion would be audio and/or video recorded. Prior to the research, respondents were to give their written consent that they accepted to participate, and that they were famil-iar with the core research topic. Especially, the participants in focus groups discussions were informed that they would receive an incentive for their participation. Similar to the

61Research Ethics

respondents who took part in the quantitative part of the research, all participants from qualitative part of the research received an introductory letter with the same information as for the quantitative research.

Also, it is important to point out that the qualitative part of the research was conducted by a very experienced moderator. The moderator has MSc in psychology and several years of experience of moderating qualitative research on different public opinion topics with representatives of general population, but also representatives of vulnerable groups like Roma population, children and people with disabilities.

The written consent forms and transcripts of interviews and focus group discussions were available to members of the research team only. These materials are protected with a code, and transcripts are depersonalised after deleting all personal data. All audio and video materials are irreversibly destroyed, guaranteeing safety and anonymity. Finally, IPSOS Strategic Marketing is bound to keep confidential all data collected in this re-search, except for the data that are to be available in the public domain, as agreed with the Client. IPSOS Strategic Marketing wasn’t engaged in any other assignment that may arouse a conflict of interest with this research assignment.

63Research Findings

Research Findings

In the following sections, the results of quantitative and qualitative research will be pre-sented. At the beginning we will show the main results of in-depth interviews with key infor-mants and health workers. Complete and detailed report from the interviews with key infor-mants and health workers is presented in Appendix 7. This is followed by detailed results of quantitative survey, together with key findings from focus group discussions with parents. Within this section, measures used in the research and way of their operationalization will be shown. Within each section, data obtained on total population will be shown first, and they will be followed by data for two groups of parents who are divided on the basis of their future attitude towards vaccination - „supporters“ and „hesitant“. At the end of each section, relevant findings from focus groups will be added. The whole report from focus group dis-cussions is presented in Appendix 8. The same sequence of data presentation was used to present the findings for Roma population.

6.1. Report from in-depht interviews with health workers and key informantsIn-depth interviews were carried out with key informants (individuals with technical or oper-ational knowledge on the in-country status of immunization) and representatives of health sector (paediatricians, paediatric nurses, visiting nurses and Roma mediators). The inclu-sion of key informants in in-depth interviews was aimed at providing a wider, contextual pic-ture of immunization in Serbia, with special focus on highlighting strong and weak points of immunization at this moment. The main aim of in-depth interviews with health workers was to get the perspective of medical professionals who are in daily contact with parents on pa-rental attitudes, knowledge and practices related to immunization. It was further to see how medical professionals and key informants assessed some key aspects of the immuniza-tion process and aspects related to legislation, vaccine supply, communication, the role of health system and institutions etc. These findings helped in acquiring the “big picture” about immunization in Serbia, which helped in contextualizing the findings collected from parents and providing some concrete recommendations for action.

6.1.1. Evaluation of legislative framework regarding immunization and success of its implementation in practiceKey informants and health workers evaluate mainly positively the actual legislative frame-work concerning immunisation. According to them, the law clearly defines the purpose of immunisation and the fact that immunisation process is of general social interest. However, both groups of respondents point out that there are problems in implementation of this law, and the fact that these problems are manifested differently in practice. They single out

6


as one of the most serious current problems the absence of a Rulebook on immunisation which significantly impedes the structure and systematization of work of all healthcare insti-tutions involved in the process of immunization. More specifically, as the basic role of this Rulebook is to determine conditions, method and indications for implementation of immuni-zation, as well as the method of keeping records of the realised immunization, it is obvious that absence of this Rulebook prevents healthcare professionals involved in the process of immunization to have the official reference point in their work. As a consequence, this can mean systematic approach in implementation of not only immunization, but also criminal policies for those who refuse to vaccinate their children

Besides that, the topic which causes conflicting opinions between key informants and healthcare workers is the question of legal obligation of vaccination – while key infor-mants consistently have a strong positive attitude towards this provision, some healthcare workers state that this obligation causes negative reactions among those parents who are not sure or who refuse to vaccinate their child, putting healthcare workers in a disadvan-taged and unpleasant position. Revolted by their negative experiences, some of the inter-viewed healthcare workers go a step further, and they state that vaccination should not be mandatory.

The last problem that is mentioned regarding the actual legal framework is non-existence of compensation fund for the children who experience serious side effects of vaccination. Judging by the attitude of respondents in this study, this causes considerably negative atti-tude of general public towards not only immunisation, but also towards the entire health sys-tem. According to them, special policies should be directed towards solving of this problem, that is, a compensation fund should be established.

6.1.2. Strong and weak links in the process of immunizationAt the moment, key informants single out legal framework, competent ministry, accessi-bility and availability of vaccines as the strongest links in the process of immunisation. Representatives of healthcare sector, both key informants and health workers emphasise more strongly the importance of paediatricians, who are in direct contact with parents, and generally previously made efforts aimed at raising parents’ awareness about the im-portance of vaccination. In this respect, Roma health mediators deserve special praise be-cause, according to respondents, they improved the vaccination coverage in Roma popu-lation significantly.

When it comes to the weakest links, answers of the key informants and healthcare work-ers are mainly matching. First of all, they point to the negative influence of the media, particularly the electronic ones, as they include false and unverified information about the impact of vaccines on children’s health. They also mention, to a somewhat lesser ex-tent, general decline of citizens’ trust in the healthcare system, as it has been in a dif-ficult position for many years, previous shortages of vaccine supply, as well as poor knowl-edge that citizens have about vaccination in general. According to some key informants, a very significant problem, and weak link is the status of the National Institute of Virology, Vaccines and Sera “Torlak”. As many of them state, it is necessary to remember that Torlak is a national company and to undertake the necessary steps and strategies in or-der to use the capacities and possibilities that Torlak has to the maximum and to mi-nimise import of vaccines. Some of the key informants believe that Torlak has a problem with their staff competence, obsolete production equipment and politicization of their work.

65Research Findings

6.1.3. Evaluation of accessibility of vaccinesOpinions of key informants and health workers about accessibility of vaccines are also di-vided. According to both groups of respondents, previous problems with accessibility and availability of vaccines were the result of poor coordination of work between compe-tent institutions and failure to recognize the need for reserves. Namely, there are opin-ions that Serbian healthcare system does not sufficiently recognize the need for vaccine stock, particularly for the recommended immunisation programme. However, this opinion is not supported by representatives of higher instances, who believe that current avail-ability of vaccines and their accessibility are at optimal level.

Experiences of healthcare workers show that problems with inaccessibility of vaccines have somewhat impaired the confidence of parents, but, according to them, efforts are being made to prevent it. Paediatric nurses and other administrative staff inform parents in good time that vaccination is postponed for several days if vaccines do not arrive in time, and parents bring their children at the agreed time. Also, there are cases when paediatric staff inform parents that they are free to buy vaccines in a pharmacy, but most of them advise parents not to do so because it is usually a matter of several days when vaccines will be available again. A number of interviewed health workers do not have a positive atti-tude towards vaccines bought in pharmacies, because they believe that the overall quality of vaccine storage is questionable, which is one of the reasons why they advise parents not to buy these vaccines.

6.1.4. Storage of vaccines, availability of accompanying equipmentAll healthcare workers state that there is a strict mechanism of regulations regarding the storage and preservation of vaccines, and that non-compliance with these regulations is prohibited by law and virtually impossible. It is also stated that these regulations also include procedures for special conditions, for example in the event of a power failure in health centre, which significantly facilitates the operation of health institutions in such con-ditions. Namely, it is pointed out that there are strict procedures that must be respected in these institutions. A paediatrician from one healthcare centre also stated that they had spe-cial trainings where they learned how to store the vaccination equipment, and one of the conditions was that only the healthcare workers with such training were allowed to work on these positions.

6.1.5. Evaluation of immunization calendarMajority of the interviewed healthcare workers perceive the vaccination calendar as the re-sult of work of epidemiologists who are most familiar with all the recommended periods for immunisation, and they have no dilemma whether current immunisation calendar is ade-quate or not. However, some healthcare workers point out that it would be preferable to change the prescribed age for MMR vaccination, again due to parents’ growing pres-sure on paediatricians to postpone MMR vaccine until the child starts speaking. According to them, this would probably reduce the number of unpleasant situations that currently oc-cur, and parents would also be more willing to accept this vaccine, which would definitely generate more positive attitude towards this vaccine.


6.1.6. Evaluation of vaccination consent/refusal formWritten consent to vaccination is perceived in different ways. According to majority of key in-formants, written consent forms for mandatory vaccination, which are not used in the coun-try at the moment, are unnecessary. They indicate that citizen (or in case of children - par-ent) accepts vaccination.

Speaking hypothetically about these consent forms, predominantly negative attitude to-wards them is detected, because many respondents believe that that these forms can arouse suspicion and mistrust. On the other hand, written consent for recommended vac-cines is evaluated positively and its use is considered justified. The purpose of con-sent to recommended vaccines is to protect the healthcare system in case of any adverse effects or unwanted events, since it means that one accepts a vaccine, for instance the one for seasonal flu, which is not specified as mandatory by the state.

However, it seems that health workers have different attitudes towards mandatory vac-cination refusal forms. Vaccination is formally refused when parents sign a statement saying that they refuse to have their child vaccinated with a mandatory vaccine. Such writ-ten statements are used in the Republic of Serbia and they also serve as a foundation for sanctioning of parents who won’t accept vaccination. The forms are to be signed at paedia-tricians’ or in health centres, while healthcare workers are to inform the relevant authorities about such cases.

The biggest criticism that some health workers express is that the forms are not standard-ized and that healthcare institutions must create the forms on their own. This is assessed as a significant problem; paediatricians state that precise wording is extremely important, so that healthcare institutions can be protected in case of any dispute with penalized par-ents. On the other hand, some paediatricians point to different interpretations of procedures in cases when vaccination is refused, since some paediatricians request parents to sign the refusal form the first time when they refuse vaccination, while other paediatricians try to ne-gotiate with them, give them time to think it over, and only after multiple refusals ask them to sign the vaccination refusal form. Furthermore, the interviewed Roma health mediators are not informed about these forms, and they state that they have no experience with them.

In compliance with the mentioned facts, some of the key informants point out that there are two kinds of problems with these refusal forms at the moment – problems arising from in-adequate behaviour of the parents who refuse to have their child vaccinated, but also the problems related to concrete sanctioning of health workers and parents whose be-haviour results in non-vaccination of the child. In other words, respondents from this phase of the research point out that there is insufficient public information about the extent to which penal measures are implemented to those paediatricians who allow parents not to vaccinate their children, as well as about the parents who decide to take this step. In the opinion of key informants, this information should be public, backed by control mechanisms that are already used in the vaccination chain. Some paediatricians report that during their practice they had only a few cases when they informed the competent authorities that par-ents refused to vaccinate their child, but did not receive any feedback from them about the outcome of the complaint.

67Research Findings

6.1.7. Evaluation of institutions included in the process of immuni-zation and their coordinationPerception of institutions

The interviewed institution representatives are satisfied with their work efficiency–higher instances in the immunisation process and representatives of the Public Health Institute in various parts of Serbia, healthcare workers themselves, and finally, individuals and rep-resentatives of informal associations, who informally improve the immunisation process in Serbia through their activities.

On the other hand, some key informants and healthcare workers often criticize higher in-stances because of insufficient media engagement and poorly opposed, ever-strong anti-vaccination movement. According to them, there are almost no examples of positive communication between national health institution representatives and health system man-agement, which directly opens an actionable gap for representatives of anti-vaccination movement who influence the public opinion. However, representatives of the highest healthcare instances don’t share this criticism, and they are quite satisfied with their public endeavours focused on vaccination.

The next mentioned problem is that healthcare institutions, especially primary health centres, as a rule, suffer from work overload. According to both key informants and healthcare workers, a significant problem is that health centres are understaffed, which considerably limits their scope of work – reducing it to interventions instead of preven-tive work. As a result, paediatricians are not sufficiently committed to their preven-tive work with patients, and they do not provide sufficient information to parents, not only about vaccination, but also about other health topics.

Perception of coordination between institutions and their collaboration

Key informants and health workers believe that coordination between all relevant participants in the process of immunization is not sufficient, and this results in failing to use the full potential of immunization in Serbia. The most common illustrative example is absence of systemic planning of acquisition of vaccines, which may lead to shortage, or to misplacement or loss of purchased vaccines. However, these cases mainly belong to the past, while the current situation is perceived a lot more positively.

On the other hand, current communication between institutions is evaluated positively. However, deeper analyses reveal clearly defined circles of communication, with defined directions and no significant deviations – so, primary healthcare centres usually commu-nicate with regional public health institutes, then they communicate with the national public health institute, which usually communicates with the Ministry of Health and the National Health Insurance Fund. Communication with the regional immunization co-ordinator is usually the responsibility of the public health institute and of paediatri-cians, who are usually satisfied with it. Such closed circles of communication may be the cause of the problems that coordination is faced with – such communication resulted in untimely reaction of relevant institutions and short or late supply of vac-cines as the final outcome. On the other hand, interviewed key informants from different associations criticise communication with the Ministry of Health, which fails to be respon-sive enough to the topical problems associated with immunization. This collaboration is aggravated by the limited budget of the Ministry of Health – this is seen as the rea-son why the recommended steps for immunization coverage are not implemented.


6.1.8. Stakeholders - communication

Communication between health workers and parents

As for communication with parents, many health workers state that they meet parents who have doubts, and parents with initially negative attitude towards immunization. The arguments that health workers use most when communicating with parents refer to personal experiences – health workers explain that they have vaccinated their children or that they plan to do so, and they also explain how important vaccination is for prevention of diseases. However, health workers also report that sometimes they feel helpless, be-cause they are being pressured by parents who believe, under the influence of the media, that vaccines are harmful. At the same time, they don’t seem very interested in committing themselves to this duty – some don’t feel competent enough to answer all parents’ ques-tions, some fear parents’ reaction if they try to persuade them, and some believe that the decision about vaccination is individual, and that doctors should not be put in a position to be forced to persuade anyone.

Health workers also claim that parents are not very likely to ask for more information about vaccines, and information they usually ask for refers to the country of origin, the list of adverse effects and shelf life of vaccines.

Communication with general public

The communication between institutions and general public is perceived very nega-tively. Respondents could not single out any institution responsible for communication with the general public, because many of them believe that all relevant instances should be en-gaged in this activity, starting from representatives of primary healthcare level, all the way to representatives of higher instances. In addition, representatives of different associations tend to underline how important it is to make this communication more transparent and more adjusted to ordinary people – with minimum usage of medical terms, and with clear explanations of the advantages and disadvantages of compulsory vaccination.

Health workers believe that insufficient parents’ knowledge is an aspect that requires more extensive engagement of all relevant stakeholders. They are most likely to consid-er higher instances responsible for this, while they consider their own responsibility largely limited due to their insufficient capacity for prevention. Furthermore, health workers be-lieve that uniform campaigns and strategies for informing parents should be devised, since this is the initial step necessary for any campaign aimed at changing the mind-set of the population.

Key informants and health workers state that they are very likely to meet parents who have read on the internet that vaccines are harmful. They notice an increasing share of parents who believe in, or at least are puzzled by, such information, while fewer and fewer parents perceive paediatricians (as experts) as their main source of information. The strongest be-lief present in general public currently refers to the connection between MMR vaccine and autism. Some citizens believe that vaccines are harmful because of their compo-sition and some believe in conspiracy theories related to pharmaceutical companies that produce vaccines for their own benefit only. The media are mainly the source of this information and respondents wonder why there is no media control regarding this issue.

69Research Findings

This atmosphere is additionally heated up by the growing anti-vaccination movement. Quite expectedly, all respondents share extremely negative opinion about this movement, espe-cially about its supporters who come from the medical profession. Individual activists are the most visible in public, while organized associations are less known. Respondents from Belgrade have some knowledge about the activities of these associations. In the opinion of many respondents, the arguments used by supporters of these ideas are absolutely un-founded, and the media, which promote these ideas to some extent, should share respon-sibility for their sensationalistic coverage. Hypothetically confronting supporters of anti-vac-cination movement in public, in a TV or radio program for instance, is perceived extremely negatively by majority of key informants, since they believe that this would only draw atten-tion and give legitimacy to the anti-vaccination movement. Parents who are perceived as most susceptible to the ideas of anti-vaccination supporters are parents of medically vulnerable children (usually children with autism). As mentioned previously, unlike key informants, health workers expect anti-vaccination attitudes to be challenged by the professional public directly, in the media, and they also expect the professional pub-lic to be pro-active and not reactive regarding this issue.

In the opinion of key informants and health workers, it is necessary to create a long-term and continuous communication strategy with the public. For instance, distribution of promotional materials such as brochures, leaflets etc., which would include the calendar of compulsory vaccination, but also clear description of the applied vaccines.

Respondents also suggest organising educational workshops for parents, especially for fu-ture parents, so that they can be adequately prepared for parenthood, and fully informed about vaccination. Documentaries are considered to be very useful. They should show the diseases that compulsory vaccination prevents, as well as clear consequences of epidem-ics. Some experienced health workers believe that not only the public, but also their young-er colleagues are not really sure which diseases vaccines prevent and what the complica-tions might be, since they have never seen them in their practice.

6.1.9. Training for lay and professional publicAttending training courses about immunization and their organisation, especially by different associations like Association of Parents or Association of Paediatricians, is com-mon. These courses are perceived as useful, empirically founded, but intended for medical professionals primarily. Key informants employed in the state sector claim that it is more difficult to organise training courses for the public, that this is always accompanied by the problem of parents’ response, but that there are future plans for providing such ac-tivities throughout Serbia.

Healthcare workers, primarily paediatricians, state that they have attended training on immunization, workshops, round-table discussions and lectures given by foreign experts. They perceive these training courses as useful. However, on these occasions, it was not un-common for them to meet their colleagues who were not sure whether to consider vaccina-tion harmful or beneficial. In addition, Roma health mediators underline the importance of attended training courses and lectures, and their contribution to improved fieldwork. Roma health mediators do not attend training courses together with other health workers.


6.1.10. Comparison with EU countriesAs for legislation in Serbia and in the EU, according to majority of the key informants interviewed, our legal frame follows general EU standards. The obvious differences re-fer to communication with parents and general raising of awareness. They point out that in some countries each parent has a calendar of vaccination with clearly defined vaccination time-frame and with a list of reasons in favour of vaccination, which is not the case in Serbia. On the other hand, healthcare workers seem to be a lot less informed about the immunization systems implemented in other countries, so they don’t know whether vaccination is compulsory in other countries and what the consequences of non-vaccination are.

6.1.11. Immunization coverage – the expected trend All respondents agree that immunization coverage is decreasing – MMR vaccine cover-age first of all. Representatives of higher instances seem to be less concerned, specify-ing that coverage is satisfactory in general. However, both key informants and health work-ers believe that coverage will continue to decline, and that only an epidemic can trigger a change.

As for vulnerable populations, Roma children are most likely to be singled out as a group at the highest risk of non-vaccination. Respondents specify different reasons for consider-ing this population as being at the highest long-term risk – while some blame the fact that these communities are inaccessible and irresponsive, others believe that actually these populations are hard to reach and that their lifestyle disables keeping compre-hensive records and monitoring of this population. Roma health mediators have a lot more positive experience. She claims that coverage has improved, but that Roma, in gen-eral, are still insufficiently informed - some of them even let their children decide whether they want to be vaccinated or not. However, the coverage of Roma population is expected to grow.

71Research Findings

6.2. The main measures used in the research

Vaccine-related behaviour

Previous vaccine-related behaviour. Respondents answered if they took their chil-dren to vaccination according to the calendar (I took him/her to get vaccinated following the vaccination calendar to My child did not get any vaccines).

Future vaccine-related behaviour. Respondents assessed their future vaccination in-tents using the same scale as for previous vaccine-related behaviour.

Previous experience with vaccination in health facility. We investigated respondents’ interaction with the health care system related to vaccination through fifteen events (e.g. I was called on the phone by the health officials when my child needed to be vaccinated; I had a question about vaccines that I did not get an answer to; There were no vaccines in the health centre; My child’s paediatrician instructed me how to react in case my child gets any adverse reaction.). The respondents answered with Yes/No.

Experiences of discrimination. Roma respondents reported previous incidents of dis-crimination ranging from subtle (They let me wait longer in the facilities) to open (They told me I wasn’t a good parent).

Knowledge and attitudes to vaccination

Knowledge about vaccination: A scale consisting of seven multiple choice questions assessing the knowledge about vaccine preventable diseases (which vaccine protects from which disease), the way vaccination protects against diseases, recommended timeline for vaccination, etc. The summary score varied between 0 and 7.

Assessment of risks and benefits from vaccination. A scale (adapted from Horne et al., 2015) consisting of twelve Lickert type statements assessing the perceived risk and benefits of vaccinating children (e.g. I am worried that children are exposed to vaccines too early in life; I am worried about possible outbreaks of vaccine preventable diseas-es). The statements were anchored with 1 (do not agree at all) and 5 (agree completely).

Myths related to vaccination. A scale consisting of thirteen Lickert type statements (in-spired by Kata, 2011) assessing the endorsement of myths related to vaccination (e.g. Vaccine against MMR causes autism. Preservatives in the vaccines are toxic; It is better for a child to overcome the disease and thus strengthen immunity than to be vaccinat-ed; All measles are essentially harmless). The statements were anchored with 1 (do not agree at all) and 5 (agree completely).

Conspiracy theories regarding the vaccination. A scale (adapted from Shapiro et al., 2016), consisting of seven Lickert type statements assessing the endorsement of vac-cine-related conspiracy theories (e.g. Pharmaceutical companies cover up dangers of the vaccines; Vaccine efficacy data is often fabricated). The statements were anchored with 1 (do not agree at all) and 5 (agree completely).


Sources of information

Sources of vaccine-related information were identified by asking about frequency of consuming different media sources for health-related issues (such as TV, newspapers, radio, official internet sites, forums, blogs, social media,….) and asking about confi-dence in all media sources that are used and preferred communication tools.

Media literacy. A scale consisting of six Lickert type statements about the “critical” me-dia consumption (e.g. I am searching for different sources of the same information on the Internet; I take into consideration whether the author of the text has an interest to represent a certain viewpoint). The statements were anchored with 1 (never) and 5 (always).

Use of different media. A scale consisting of eight different information sources (e.g. TV, print, official Internet sites, social media, health providers, friends, family, other par-ents…). Respondents assessed how often they get health-related information via each of these sources using a scale from 1 (never) to 5 (always).

Confidence in the media. Parents assessed their trust in each source they claimed they use in the previous block. They used a five-point scale anchored with 1 (I don’t trust it at all) to 5 (I completely trust it).

Preferred communication tools. Respondents were asked how they would like to re-ceive information about the vaccines. They were given eight options (e.g. Written bro-chures in health centres that can be taken home; Posters in health centres that can be read while waiting; Websites offering a possibility to pose online questions to paediatri-cians, immunologists, more time to talk to their paediatrician) and answered with Yes/No.

Confidence in the medical authorities. Respondents assessed their trust in nine dif-ferent institutions or treatment methods (e.g. paediatrician, nurse, health system, alter-native medicine, official medicine). They used a five-point scale anchored with 1 (I don’t trust it at all) to 5 (I completely trust it).

Trust in science. Respondents assessed their attitude towards modern science through four statements (e.g. I am amazed by the achievements of modern science; I think that science will find the cure for most currently incurable diseases in the future.). The state-ments were anchored with 1 (do not agree at all) and 5 (agree completely).

Socio-demographic characteristics

Gender of parents

Age of parents

Education of parents

Type of settlement (urban/rural)

Region

Employment status

Socio-economic status

73Research Findings

6.3. Report from the quantitative and qualitative research - general population

6.3.1. Vaccination-related behaviour – general population We measured previous and past vaccine-related behaviour of parents and caregivers in Serbia. Previous vaccine related behaviour was assessed by asking respondents if they took their children to vaccination according to the calendar (I took him/her to get vaccinated following the vaccination calendar to My child did not get any vaccines). Future vaccine-re-lated behaviour was assessed by asking respondents about their future vaccination intents using the similar, adapted scale as for past vaccine-related behaviour.

The research looked into past vaccination-related behaviour and asked parents if they took their child (or in case of more children, the youngest child in the family) to get him\her vacci-nated. Large majority of parents state that they took their child to vaccination in compliance with vaccination calendar (92%); 4% claim to have been hesitant about some vaccines and delayed administration of some mandatory vaccines, but they still took children to vacci-nation. Additional 3% vaccinated their child with some while they refused other mandatory vaccines. Less than 1% (0.4%) of the parents state that their child has not received a sin-gle vaccine20.

20 When these data are compared with the data from MICS survey (MICS, 2015) according to which 80.6% of population of children aged up to 36 months received all planned vaccines (it is difficult to make comparison with Batut data because the evidence is kept for individual vaccines, and the source of information are not parents but health institutions), it can be concluded that the resulting discrep-ancy was expected due to several reasons: a. our survey covers parents of children up to 7 years of age, while MICS data covers children up to 3 years of age; b. in actual survey, in contrast to MICS, we did not ask to see the vaccination booklet, so the answers are actually estimates of the parents.

Figure 6.3.1 – Previous behaviour related to child’s vaccination

% who vaccinated their childrenaccording to schedule

% who were hestitant, but steel vaccinated

% who allowed only some vaccines

% who refused vaccination completely

92%

4%3%

0,4%


N N u

nw

sig

% w

ho v

acci

nate

d th

eir c

hild

% w

ho w

ere

hesi

tant

. bu

t stil

l vac

cina

ted

% w

ho a

llow

ed o

nly

som

e va

ccin

es

% w

ho re

fuse

d va

ccin

atio

n co

mpl

etel

y

821 821 92.3 4.3 3.0 0.4

Gen

der Male 8* 9*

1.00100 0.0 0.0 0.0

Female 813 812 92.2 4.4 3.1 0.4

Age

cate

gory Up to 30 y. 368 357

0.0693.0 2.7 4.2 0.1

More than 30 y. 453 464 91.7 5.7 2.1 0.5

Educ

atio

n Primary or less 97 61

0.11

96.2 0.9 2.9 0.0

Secondary 481 467 93.9 3.2 2.6 0.3

Faculty 243 293 87.5 7.9 3.9 0.6

Type

of

settl

emen

t

Urban 524 5440.01

90.3 6.1 3.3 0.3

Rural 297 277 95.8 1.2 2.6 0.5

Reg

ion

Belgrade 191 212

0.73

90.5 4.8 4.0 0.8

Vojvodina 215 226 95.2 2.4 2.4 0.0

Central Serbia 415 383 91.6 5.1 2.9 0.3

Empl

oym

ent

stat

us

Employed 411 435

0.26

92.2 5.3 2.2 0.4

Unemployed 177 166 90.8 2.7 5.8 0.8

Housewife/Pensioner/Student 233 220 93.5 4.0 2.5 0.0

Fina

ncia

l si

tuat

ion

Low 165 153

0.91

93.5 3.7 2.6 0.2

Medium 383 385 92.7 4.3 2.6 0.4

High 207 223 89.9 5.3 4.3 0.5

Futu

re b

ehav

iour Will vaccinate 651 653

0.00

98.6 0.9 0.4 0.0

Probably will vaccinate 113 111 82.0 13.9 4.1 0.0

Will give some vaccines 37 37 32.9 29.5 37.6 0.0

Will not vaccinate 8* 8* 30.5 0.0 37.9 31.6

Table 6.3.1 – Past vaccination behaviour, breakdown by demographics

*:N<25, data is not analysed.

75Research Findings

When observing different background variables in general population, it is obvious that there are no major differences in reported vaccination behaviour as per socio-demograph-ic characteristics. Higher educated parents were somewhat more likely in the past to delay some vaccines and were hesitant about immunization (8%), followed by a parents living in urban areas (6%) Parents in rural areas (96%) followed immunization calendar more than parents from rural areas (90%). Among parents that are not employed there a slightly more of those who allowed only some vaccines (6%). Parents with highest financial status were less likely in the past to strictly follow immunization calendar then those parents from lower economic status groups (90% from highest economic status groups comparing to 94% of parents from the lowest socioeconomic status).

As for the parents from focus group discussions who oppose vaccination, they behave in different ways – some of them have given their children all vaccines but MMR, which they are postponing, some gave only BCG vaccine after birth, or BCG vaccine and the vaccine against hepatitis B, while some gave all the planned vaccines to their children, but that they still have negative attitude towards them.

Speaking about postponing of vaccination, majority of parents with positive attitude towards vaccination postpone it because of child’s sickness. Two of all the interviewed parents with positive attitude towards vaccination say that they have postponed vaccination out of fear, MMR vaccine both. One of these parents didn’t inform the doctor about this decision, but lied how child was sick, while the other one postponed vaccination because the doctor recommended it. Parents with negative attitude towards vaccination are likely to postpone vaccination, MMR again. Some have postponed it for several times, but still haven’t made a solid decision whether to vaccinate their child or not, because they are waiting until child reaches a certain development phase (for instance starts to speak). These parents also report that they have heard of cases of autism after receiving MMR vac-cine, which made them suspect. These parents mainly avoid vaccination, while some told their paediatricians openly that they didn’t want their children to receive this vaccine.


When it comes to parents’ intention to vaccinate children in the future, the situation is somewhat different in general population: although majority of parents do not have any di-lemmas and claim that they would definitely comply with the vaccination calendar (79%), their percentage is smaller when compared with past vaccination behaviour. Not such a negligible percentage of parents claimed that they would probably vaccinate their children (around 14%), while additional 4% of parents stated that they would refuse some vaccines, and accept other vaccines. The percentage of definite vaccine refusers is still small (1%).

Figure 6.3.2 – Future vaccination behaviour

81%

14%

4%

1%

% who will certainly follow the schedule

% who will probably follow the schedule

% who will refuse some vaccines

% who will refuse to get child vaccinated at all

In the following analyses, we compare clusters of parents formed by vaccination intentions (future vaccination behaviour), according to various sociodemographic characteristics in or-der to ascertain whether hesitant parents are recruited from certain parts of the population – urban or rural, younger or older, with higher or lower education, with higher or lower so-ciodemographic status.

There are no significant differences between the clusters by any assessed characteristic in general population; the percentage of hesitant parents is somewhat higher in urban than in rural settlements (9% in rural settlements comparing to 17% in urban settlements), in age group above 30 years of age (15% comparing to 12% among younger parents), and among less educated parents (primary and secondary school). Such profile indicates that hesitant parents are recruited among privileged strata of the population, but, in order to obtain a more reliable conclusion, it would be necessary to follow trends and ascertain whether the differences are maintained on the same level or decreasing.

The presented distribution of parents as per their vaccination intentions provides the basis for their grouping into two clusters a) those who support vaccination and intend to vaccinate their children and b) those who have still not made their final decision and are stating that “will probably vaccinate” and those who will selectively give only some vaccines from the mandatory list (Figure 6.3.3.).

77Research Findings

N N u

nw

sig

I will

certa

inly

get

him

/he

r vac

cina

ted

follo

win

g th

e sc

hedu

le.

I will

prob

ably

get

him

/he

r vac

cina

ted

follo

win

g th

e sc

hedu

le.

I will

get h

im/h

er v

acci

nate

d fo

r som

e va

ccin

es. a

nd

refu

se th

e ot

hers

.

I will

refu

se to

get

him

/he

r vac

cina

ted

at a

ll.

Don

't kn

ow. r

efus

al

824 824 79.0 13.8 4.4 1.0 1.8

Gen

der Male 8* 9*

1.0082.8 17.2 0.0 0.0 0.0

Female 816 815 79.0 13.7 4.5 1.0 1.8

Age

cate

gory Up to 30 y. 370 359

0.5979.7 12.0 4.8 1.1 2.3

More than 30 y. 454 465 78.4 15.2 4.2 0.9 1.4

Educ

atio


0.91

82.2 16.0 0.9 0 0.9

Secondary 483 469 80.0 12.2 5.1 1.1 1.5

Faculty 244 294 75.7 16.0 4.4 1.1 2.7

Type

of

settl

emen

t

Urban 525 5460.01

75.1 16.7 5.1 1.1 2.1

Rural 299 278 85.9 8.7 3.3 0.8 1.3

Reg

ion

Belgrade 194 215

0.82

76.8 12.9 5.2 1.1 3.9

Vojvodina 215 226 84.7 10.8 4.1 0.0 0.4

Central Serbia 415 383 77.0 15.7 4.3 1.4 1.5

Empl

oym

ent

stat

us

Employed 411 435

0.77

80.4 12.1 5.1 1.0 1.5

Unemployed 177 166 74.8 18.1 3.9 2.3 0.9

Housewife/Pensioner/Student 236 223 79.8 13.5 3.7 0.0 3.0

Fina

ncia

l si

tuat

ion

Low 165 153

0.62

76.4 17.0 3.2 0.0 3.5

Medium 383 385 81.4 12.6 4.9 0.8 0.3

High 207 223 76.9 13.9 5.2 2.4 1.6

Futu

re b

ehav


0.00

100 0.0 0.0 0.0 0.0

Probably will vaccinate 113 111 0.0 100 0.0 0.0 0.0

Will give some vaccines 37 37 0.0 0.0 100 0.0 0.0

Will not vaccinate 8* 8* 0.0 0.0 0.0 100 0.0

Table 6.3.2 – Future vaccination behaviour, breakdown by demographics, general population

* N<25, podaci nisu analizirani.


The second group includes two sub-groups of parents who can be tagged as hesitant. Vaccine hesitancy, as defined by the WHO, includes both delay and selective acceptance of vaccines: Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context-specific vary-ing depending on time, place and the vaccines in question. It includes factors such as com-placency, convenience and confidence (www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/).

There are two reasons for grouping two categories of hesitant parents into one group. The first reason is that research shows that although they state different reasons for their hesi-tancy and that there can be a lot of fluctuation from one reason of hesitancy to another, in communication they can be treated as one group which needs support and empowerment in their decision- making.

The second reason is that the number of parents who claim that they will refuse certain vac-cines for their child is relatively small (4% in general population), which doesn’t allow so-phisticated statistical analysis of this group separately – even crosstabs by certain criteria would result in a small number of respondents per cell (fewer than five in some cases)21.

The last group of parents who state that they will not vaccinate children was excluded from this comparison, and grouping to “supporters” and “hesitant” parents will be followed through further data analysis due to two reasons: a) their percentage is very small in gen-eral population (total 1%), b) the related research shows that communication efforts should be directed towards hesitant parents, since it is very difficult to influence those with formed, extreme attitudes. Some studies show that such attempts resulted in further radicalisation (the so-called “boomerang effect”).

22

21 In the Annex with cross tabulation, however, all four groups are kept separate so the reader can track their answers question by ques-tion.22 Since we excluded from analysis those parents who state that they will refuse all vaccines, we made a total of 100% of those who were full supporters and hesitant toward some vaccines, and therefore percentages do not fully match those on general population in the analysis that follows. For example, in the new breakdown to supporters and hesitant, there are 81.3% of supporters and 18.7% of hesitant parents in general population, without definite refusers.

Figure 6.3.3 – Proportion of two clusters in the population – vaccination-supporters andvaccination-hesitant parents

I’ll surely vaccinate

HesitantNote: parents who oppose vaccination are excluded from calculation22

81%

19%

79Research Findings

6.3.2. Previous experience with vaccination of the youngest child – general populationParents’ experience with the health care system during the previous vaccination was ex-plored through fifteen parameters related to different aspects of interaction between parents and the health system to see if there are issues that potentially influence vaccination be-haviour. It included questions on whether parents took children to vaccination on their own, if this practice was facilitated by phone of mail invitations from health institutions, whether a paediatrician provided basic information about vaccination (schedule, vaccine and its pos-sible side effects etc.) and examined a child before vaccination, whether vaccine was avail-able, about waiting time in health facility and finally if a child had any negative reactions. Parents were finally asked to assess if the vaccination experience was generally positive or not. All questions had yes/no answer modalities. We also included special section for Roma population: experiences of discrimination. Roma respondents reported previous incidents of discrimination ranging from subtle (They let me wait longer in the facilities) to open (They told me I wasn’t a good parent). Those questions will be presented in sections with Roma population.

Most parents stated that they were informed about the next vaccination (86%), about dis-eases which are prevented with the administered vaccine (76%), about side effects (79%) and how to deal with them if they appear (82%). 42% of parents from the general population stated that their child had a mild reaction to the vaccine, and only 3% stated that child has a strong reaction. Some parents (17%) weren’t answered their questions about vaccination and their percentage is higher among residents of Belgrade (25%). Vaccine shortage was reported by 14% of parents.

No significant differences in vaccination experience emerged when respondents’ answers were broken down by age, education, region, employment and financial situation. About 17% were invited by phone or sent written notification from the health facility and it seems that this practice is more common in rural areas (22%). In rural areas, parents experienced less waiting for vaccination in the health centre (16%), indicating that health centres in ur-ban areas are more crowded (25%). Parents from Belgrade stated more frequently that they were left with unanswered questions after visiting a doctor (25%).

We proceed to compare vaccine hesitant and vaccine supportive parents’ vaccination ex-periences. Although the registered differences between the two groups are not drastic, they are systematic and obvious on all questions. Higher percentage of supporters of vaccina-tion report that they took the child to vaccination in the healthcare centre on their own and according to the vaccination calendar, while higher percentage of hesitant parents state that they were contacted by an institution (by phone or written notification), an indicator of an ef-fort by the health system to reach this specific subpopulation. The experience in the health-care centre is significantly more positive among supporters of vaccination, while hesitant parents claim to have had a question which health workers could not answer (30%), that they were not informed about the diseases against which the vaccines were given, what the side effects were and how to behave in such cases. Higher percentage of them also report mild reactions to vaccines (swelling, temperature) 50%. Also hesitant parents were more likely to report about the lack of vaccines (20%), and longer waiting 28%. However, all things considered, the data do not indicate negative experience in either group, and when they were asked to give overall assessment of their experience, parents agreed that the ex-perience was positive (96% of supporters and 84% of hesitant parents).


N N u

nw

I too

k th

e ch

ild t

o th

e va

ccin

atio

n fo

llow

ing

the

cale

ndar

I was

invi

ted

by p

hone

I rec

eive

d w

ritte

n no

tice

to c

ome

821 820 88.3 17.2 17.6

GenderMale 8* 9* 76.4 7.0 17.2

Female 813 811 88.4 17.4 17.6

Age categoryUp to 30 y. 370 358 88.0 18.1 17.4

More than 30 y. 452 462 88.5 16.5 17.7

Education

Primary or less 97 61 91.8 20.8 18.4

Secondary 482 467 88.3 18.8 18.6

Faculty 243 292 86.7 12.8 15.3

Type of settlementUrban 524 544 88.5 14.5 16.2

Rural 297 276 87.8 22.1 20.0

Region

Belgrade 192 213 86.7 10.9 15.4

Vojvodina 215 226 84.6 22.1 13.5

Central Serbia 414 381 90.9 17.7 20.7

Employment status

Employed 409 433 87.4 15.8 17.9

Unemployed 176 164 93.5 16.5 17.3

Housewife/Pensioner/Student 236 223 85.8 20.4 17.3

Financial situation

Low 164 152 91.2 17.2 16.5

Medium 381 383 89.2 17.3 17.8

High 206 222 81.6 17.7 19.6

Future behaviour

Will vaccinate 651 652 88.9 15.4 17.2

Probably will vaccinate 113 111 88.4 26.1 23.0

Will give some vaccines 37 37 79.1 25.0 11.9

Will not vaccinate 6* 5* 86.1 24.3 0.0

Table 6.3.3 – Experience with vaccination, break down by demographics, % of YES answers (Base: respondents whose children have been vaccinated at least one time (99% of target population)

Note: N<25, data is not analysed.

81Research Findings

Note: N<25, data is not analysed.

paed

iatri

cian

info

rmed

me

abou

t the

nex

t im

mun

izat

ion

I was

n’t a

nsw

ered

m

y qu

estio

n

I was

giv

en th

e im

mun

izat

ion

cale

ndar

I wai

ted

long

er th

an

half

an h

our

ther

e w

ere

no

vacc

ines

ava

ilabl

e

child

was

exa

min

ed

befo

re v

acci

natio

n

I was

info

rmed

abo

ut th

e pu

rpos

e of

the

vacc

ine

I was

info

rmed

abo

ut

adve

rse

effe

cts

he in

form

ed u

s ho

w to

re

act t

o ad

vers

e ef

fect

s

Chi

ld h

ad a

mild

reac

tion

Chi

ld h

ad a

stro

ng re

actio

n

gene

rally

pos

itive

86.4 16.9 78.7 21.4 14.0 95.9 76.3 78.6 81.6 42.4 3.3 89.5

100 12.0 88.9 12.0 15.7 100 81.0 93.0 100 20.3 0.0 100

86.3 16.9 78.6 21.4 13.9 95.9 76.2 78.5 81.4 42.7 3.3 89.4

84.7 16.3 78.1 23.7 10.9 96.4 74.3 79.2 82.0 41.3 3.3 89.2

87.8 17.3 79.1 19.5 16.5 95.5 78.0 78.1 81.2 43.4 3.2 89.9

90.3 15.6 81.0 17.6 16.2 95.8 84.6 87.8 91.5 28.7 0.0 92.9

86.3 17.0 82.3 20.9 10.3 96.0 77.6 80.7 81.7 44.3 3.9 89.2

85.2 17.1 70.7 23.7 20.3 95.9 70.5 70.9 77.3 44.3 3.4 89.0

86.8 19.2 76.9 24.6 15.3 95.5 74.8 76.4 80.7 44.7 4.3 88.7

85.9 12.8 81.8 15.6 11.7 96.8 78.9 82.6 83.1 38.4 1.5 91.0

83.9 24.9 70.3 23.5 15.3 94.0 69.8 70.4 75.7 43.9 6.1 86.9

90.2 11.8 76.9 22.2 15.0 96.2 78.1 80.9 83.6 46.3 2.0 90.9

85.6 15.7 83.5 19.9 12.8 96.7 78.4 81.2 83.3 39.8 2.6 90.1

85.5 16.1 78.9 21.9 14.2 94.5 74.5 78.4 79.9 44.0 3.3 91.0

87.9 22.1 83.4 24.6 19.5 99.1 80.0 84.1 86.5 46.2 6.0 86.8

87.0 14.3 74.8 17.9 9.4 96.0 76.7 74.9 80.8 37.0 1.2 89.1

86.6 22.3 76.7 26.7 14.5 92.9 77.0 74.2 80.4 44.3 5.1 88.4

86.9 15.7 79.5 18.4 14.3 97.4 80.9 84.8 84.3 39.9 1.5 92.0

85.8 17.6 80.1 20.4 12.6 94.3 70.3 75.0 79.5 47.1 4.3 87.3

88.3 12.8 80.0 19.7 12.6 96.3 79.9 82.5 84.5 40.5 2.4 93.8

83.8 21.9 76.0 26.1 17.3 96.0 69.3 69.4 73.9 45.5 3.3 81.0

75.4 48.7 69.5 29.2 24.6 91.3 51.2 45.6 58.3 60.4 2.2 62.9

50.0 75.7 100 24.3 20.2 100 25.7 61.8 86.1 29.8 29.8 56.3


Figure 6.3.4 – Experience with vaccination, comparison of supporters of vaccination and hesitant parents,% of YES answers

Total HesitantsSupporters

I took a child to vaccination followingthe vaccination calendar.

88,3%88,9%

86,6%

I was called on the phone by thehealth officials when my child neededto be vaccinated.

17,2%15,5%

25,7%

I received a written notification on myadress from the health officials informing me that my child need to be...

17,6%17,5%20,5%

My child’s pediatrician informed meabout the next date for vaccinationmy child need to receve...

86,4%88,8%

82,7%

I had a question that I didn’t getanswer to.

16,9%12,9%

30,3%

I was given immunization calender.78,7%80,9%

74,3%

I waited for a long time (more thanhalf an hour) for a vaccine in thehealth center.

21,4%20,1%

27,9%

There were no vaccines in the healthcenter.

14%12,8%

19,6%

My child was examined by pediatricianfor health status before vaccination.

95,9%96,7%95,2%

My child’s pediatrician informed meabout the disease my child is gettingvaccinated against.

76,3%81,6%

67,4%

My child’s pediatrician informed meabout potential side-effects from thevaccine.

78,6%83,4%

64,9%

My child had a mild adverse reaction(swelling, temperature) to vaccine that cleared quickly and did not require any...

81,6%85,1%

71,4%

My child had a severe adverse reactionto vaccine that needed to be treatedmedically and reviewed and reported...

42,4%41,1%

50%

In general, my experience wihvaccination was positive.

3,3%2,4%3,3%

My child’s pediatrician instructed mehow to react in case my child gets any adverse reaction.

89,5%96,1%

83,7%

83Research Findings

Focus groups discussions reveal that parents from general population have various expe-riences with the health sector, especially when it comes to vaccination. In general, primary health centre is a place where all parents from general population, irrespective of their atti-tude towards vaccination, seek healthcare services. On the other hand, interviewed parents have different attitudes towards the health system and its staff. Parents who oppose vacci-nation emphasize having negative experiences in state health institutions, such as with im-polite staff, nurses first of all, inadequate doctors’ attention, long waiting time, and the process of making appointments. On the other hand, parents with positive attitude toward vaccination have somewhat positive attitudes toward healthcare workers and health centres.

When it comes to specific experiences, such as activities of healthcare institutions aimed at inviting parents to preventive examinations of children, and vaccination, parents have different experiences. Parents with positive attitude towards vaccination of children state that they have been invited to regular health check-ups only and never to vaccination. Their paediatrician enters in the vaccination booklet when they are to come for a vaccine, so they do it and no one invites them. Parents with negative attitude towards vaccination usually have been invited to vaccination by healthcare institutions. These are mainly phone calls, and it’s important to mention that not all parents who are late with vaccination have been invited. Only a few parents were delivered a written invitation.

Next, parents from general population, both those with positive and those with nega-tive attitude towards immunization, are familiar with the vaccination calendar. Parents who vaccinate their children have the vaccination booklet in which paediatricians write down the schedule of vaccination, or information about the received and scheduled vac-cines. Parents with negative attitude towards vaccination, but those who have vaccinat-ed their children, are also informed because they also have the vaccination booklet. However, parents with extreme attitude, those who have never vaccinated their chil-dren, strongly ignore everything about vaccination, including the vaccination calen-dar – some have the booklet because they were given one when child was born, but they ignore it, they don’t know when vaccination is due, and they don’t know all this because they are not interested. These parents are quite likely to say that they have never been given a brochure or calendar of vaccination in health centres.

Also, all focus group participants who vaccinate their children mention that they have been in a situation, at least one time, that vaccine wasn’t available in a health centre or that they were recommended to buy a vaccine. Parents explain how paediatricians or nurs-es contacted them directly or by phone and informed them that vaccines were late, or how they were suggested to buy vaccines in the pharmacy. It used to be unclear whether parents were to buy Pentaxim or not. Doctors used to recommend them to buy it, which majority of parents with positive attitude towards vaccination did. Parents with neg-ative attitude towards vaccination, who had already given some vaccines to their chil-dren, have different experiences with purchase of vaccines. Some say that they bought vaccines because it was recommended by their doctor, while others bought them because they heard about children’s milder reaction to them.

As for the previous experiences with vaccination, parents with positive attitude towards vaccination state that application of vaccines went smoothly, without problems, and that they detected mild reactions, such as fever or mild redness, which were expected. They were familiar with these potential effects because paediatrician informed them


about this before giving vaccines, they collected information on their own, and finally they heard testimonials of other people. However, some parents state that vaccination is certainly traumatic and stressful for children, but that they are satisfied with paedia-tricians’ work. Parents who oppose vaccination and who have given some vaccines, have different experiences. Some mention the same reactions of children as parents with positive attitude do, while others mention more serious reactions, which pro-voked even more severe suspicion. In addition, some of these parents react a lot more negatively to the expected reactions than supporters of vaccination do.

85Research Findings

6.3.3. Knowledge of general population about vaccination – general populationKnowledge about vaccination was assessed with a scale consisting of seven multiple choice questions assessing the knowledge about vaccine preventable diseases (which vaccine protects from which disease), the way vaccination protects against diseases, recommend-ed timeline for vaccination, etc. The summary score varied between 0 and 7.

Parents were asked whether they knew how vaccination protects against disease, if there are groups of children who shouldn’t be immunized, which diseases are prevented with BCG, MMR and DiTePer vaccines, what the best timeline for immunization is and what re-vaccination is. The distribution of correct answers as per each of the questions is given in Table 6.3.4 and reveals very low percent of parents who knew even the relation between certain vaccines and diseases they prevent.

The distribution of the number of correct answers is presented in Figure 6.3.5. and it shows that more than 10% of parents did not give a single correct answer, while only 1.4% an-swered all questions correctly. More than half of parents (52%) gave a correct answer to two or fewer than two questions.

Table 6.3.4 – Percentage of respondents who answered individual test questions correctly

Knowledge about immunization %

Population that answered correctly

Do you know how vaccination protects against diseases? (Correct answer: Inserting a small amount of the

infective agent to trigger immune response)32

Some groups of children should NOT be immunized. What groups are those?

(Correct answers: Children with fever higher than 38.5 C; Children with diagnosis of compromised immune system;

Children who are allergic to ingredients in vaccines)

15

Do you know which disease is prevented by BCG vaccine?(Correct answer: Tuberculosis)

59

Do you know which disease is prevented by MMR vaccine?(Correct answer: Mumps; Measles; Rubella)

24

Do you know which disease is prevented by DiTePer vaccine?

(Correct answer: Diphtheria, Tetanus; Pertussis)16

Do you know what the best timeline for the vaccination is? (Correct answer: All mandatory vaccines should be taken until 15 months of age)

50

Do you know what re-vaccination is? (Correct answer: Giving another dose of vaccine to make

immunity against the disease stronger and last longer)68

All answers correct 1


Parents mainly answered correctly the question about revaccination, about BCG vac-cine and the diseases it was related to; somewhat less than half of them knew the rec-ommended time for vaccination. Only one third of the parents could recognise the vac-cination principle and answered correctly the question how vaccination protects against the disease; one in five parents knew what MMR vaccine is and the diseases it was re-lated to (this was particularly interesting, since it concerns a vaccine stigmatized in the media because of alleged connection with autism), while one in seven parents knew which diseases are prevented by DiTePer vaccine.

Interestingly though, the connection between the test results as an objective assess-ment and answers to the question “How much are you informed about vaccination” as a subjective assessment, is very weak (correlation coefficient r=.125**). This means that respondents overestimated the level of their knowledge. In other words, they were not aware whether and how much they didn’t know.

Older parents, university educated parents, and those with better economic situation know more about vaccination than younger parents in general population. Younger par-ents exhibited less knowledge than older ones; on average, parents with higher educa-tion had twice as good a result compared with those with finished primary education; the survey registers a slight tendency of knowledge increase with higher self-assessed socio-economic status. This is valid for all asked questions. Parents from the rural ar-eas give less accurate answers if individual issues are being considered in comparison with parents from Belgrade.

0

15

20

25

10

5

None Three Four Five Six All correctTwoOne

Figure 6.3.5 – Share (%) of number of correct answers on knowledge test about vaccination in population

11,3%

17,7% 17,7%

13,8%

7,8%6,9%

1,4%

23,4%

87Research Findings

N N u

nw

Do

you

know

how

vac

cina

tion

prot

ects

aga

inst

dis

ease

?

Som

e gr

oups

of c

hild

ren

shou

ld N

OT

be im

mun

ized

. W

hat g

roup

s ar

e th

ose

Do

you

know

aga

inst

whi

ch

dise

ase

is B

CG

vac

cine

?

Do

you

know

aga

inst

whi

ch

dise

ases

is M

MR

vac

cine

?

Do

you

know

aga

inst

whi

ch

dise

ases

DiT

ePer

vac

cine

?

Do

you

know

wha

t the

bes

t tim

elin

e fo

r the

vac

cina

tion

is?

Do

you

know

wha

t re

vacc

inat

ion

is?

All a

nsw

ers

are

corre

ct

in G

sec

tion

824 824 32.5 1.6 58.7 24.2 16.2 49.9 67.8 1.4

Gen

der Male 8* 9* 51.4 0.0 48.4 9.7 5.0 70.6 65.0 0.0

Female 816 815 32.3 1.6 58.9 24.4 16.4 49.6 67.8 1.4

Age

cate

gory Up to 30 y. 370 359 28.1 1.9 54.7 21.9 15.0 48.6 66.7 1.2

More than 30 y. 454 465 36.0 1.4 62.0 26.1 17.3 50.9 68.6 1.5

Educ

atio

n Primary or less 97 61 6.8 0.0 35.9 9.7 3.9 40.2 43.9 0.0

Secondary 483 469 27.0 2.2 55.7 19.2 12.9 51.3 66.9 0.7

Faculty 244 294 53.5 1.2 73.8 39.8 27.8 50.9 78.9 3.3

Type

of

settl

emen

t

Urban 525 546 39.5 1.9 65.6 31.3 20.5 48.5 69.9 1.8

Rural 299 278 20.1 1.2 46.7 11.7 8.8 52.3 64.0 0.6

Reg

ion

Belgrade 194 215 43.4 1.4 76.5 30.5 21.4 45.6 76.7 1.9

Vojvodina 215 226 37.7 0.8 63.1 26.7 18.7 58.8 73.2 2.3

Central Serbia 415 383 24.7 2.1 48.2 20.0 12.6 47.2 60.8 0.7

Empl

oym

ent

stat

us

Employed 411 435 36.7 1.4 64.1 26.0 18.6 49.8 70.2 1.3

Unemployed 177 166 28.9 0.8 52.7 21.1 11.6 51.1 62.8 1.9

Housewife/Pensioner/Student 236 223 27.8 2.7 54.0 23.5 15.6 49.1 67.3 1.1

Fina

ncia

l si

tuat

ion

Low 165 153 23.8 1.9 50.4 17.4 10.5 44.2 56.3 1.7

Medium 383 385 34.6 2.2 60.5 28.8 18.3 51.8 68.9 1.6

High 207 223 39.1 1.0 66.3 28.1 17.2 49.3 74.9 1.0

Futu

re b

ehav

iour Will vaccinate 651 653 31.0 1.7 58.7 23.1 16.6 53.0 66.2 1.4

Probably will vaccinate 113 111 38.9 1.8 61.4 23.6 11.8 36.1 77.6 0.0

Will give some vaccines 37 37 39.4 0.0 57.3 37.9 27.9 49.3 69.6 5.5

Will not vaccinate 8* 8* 43.7 0.0 50.4 54.8 6.4 53.2 58.2 0.0

Table 6.3.5 – Share of correct answers on knowledge test, breakdown by demographics



There is no significant difference between clusters of parents when it comes to the test re-sults – although the percentage of supporters is higher among those with the lowest scores, and percentage of hesitant parents is higher among those with medium scores (3 or 4), in the group with five correct answers, there are twice as many supporters of vaccination as there are hesitant parents. Such distribution makes it impossible to draw a reliable conclu-sion about any systematic connection.

Figure 6.3.6 – Share of correct answers on knowledge test, comparison between supporters of vaccinationand hesitant parents

11%11%

9%

19%19%19%

24%24%

23%

19%18%

23%

14%14%

15%

8%8%

6%

5%5%

6%

0%0%0%

0

1

2

3

4

5

6

7

Total HesitantSupporters

During focus group discussions, knowledge wasn’t examined in the same way as in the quantitative survey. Questions were more general, with spontaneous answers, so it can be concluded that parents from general population are aware of some basic facts about vaccination.

So, spontaneously, parents usually mention tuberculosis, measles, hepatitis B, mumps as diseases that vaccination protects children from. The listed conse-quences of these diseases are usually sterility among men after mumps, as well as death because of measles, but also polio and suffocating. Parents, however, mention the consequences unsystematically, without associating specific diseases with them.

89Research Findings

Speaking of epidemics, not many parents can specify concrete ones in the past that were stopped with vaccines. Quite expectedly, supporters of vaccination are better in-formed about these topics and they mention smallpox, tuberculosis, measles. Parents who oppose vaccination mention just some of the diseases and doubt their causes – such as the recent epidemic of measles in Romania, which they consider a marketing trick designed to make parents vaccinate their children. At the same time, knowledge or lack of knowledge about past epidemics doesn’t influence the attitude towards vaccination. Majority of parents believe that epidemics may take place in the future, but parents with positive attitude towards vaccination are scared be-cause of this, while majority of parents with negative attitude don’t worry much about this, believing that children can be cured from any disease.

6.3.4. Assessment of risks and benefits from vaccination – general populationWe assessed risks and benefits from vaccination using the scale (adapted from Horne et al., 2015) consisting of twelve Lickert type statements assessing the perceived risk and benefits of vaccinating children (e.g. I am worried that children are exposed to vac-cines too early in life; I am worried about possible outbreaks of vaccine preventable dis-eases). The statements were anchored with 1 (do not agree at all) and 5 (agree com-pletely). The data were segregated to present the share of respondents who answered 4 and 5.

According to the previous data sets, the biggest portion of general population state that vaccination is useful (84%), and that vaccination should be mandatory (72%), although 40% state that parents who refuse to vaccinate children should bear the consequences, 77% is worried that their child will get a disease if not vaccinated. So, parents are more likely to recognise benefits than barriers of vaccination. However almost half of general population members (49%) agree (completely or somewhat) that they are worried about the side effects of vaccines, 44% are worried that vaccines could trigger other diseas-es, 34% state that they are worried about multiple vaccines in one take. 47% of parents were worried about the quality of vaccines.

When assessment of vaccine-related risks was analysed by socio-demographic data, again the same pattern emerged: only education and region were somewhat significant in general population. Less educated parents reported to be less worried about side effects of vaccines (34%), other diseases that can be triggered by vaccination (28%), risks about multiple vaccines in one shot (21%) or too early age for vaccinating (14%). Belgrade parents reported being more worried about all those issues, in comparison to parents from Vojvodina, who seem to be less worried. 60% of parents from Belgrade were worried about the side effects of vaccines comparing to 38% in Vojvodina. 53% of parents from Belgrade reported that they were worried that vaccine could trigger other diseases comparing to 34% of parents from Vojvodina.


* N<25, podaci nisu analizirani.

N N u

nw

I am

wor

ried

abou

t the

si

de e

ffect

s of

vac

cine

s

I am

wor

ried

that

vac

cine

s ca

n tri

gger

oth

er d

isea

ses

I am

wor

ried

abou

t the

mul

tiple

va

ccin

es in

one

take

824 824 49.1 43.9 34.3

GenderMale 8* 9* 44.9 17.2 17.2

Female 816 815 49.2 44.2 34.5


More than 30 y. 454 465 48.5 44.8 32.3

Education

Primary or less 97 61 34.1 27.5 20.9

Secondary 483 469 50.1 46.2 37.0

Faculty 244 294 53.1 45.9 34.3


Rural 299 278 41.8 38.0 28.3

Region

Belgrade 194 215 59.7 53.4 45.5

Vojvodina 215 226 38.0 33.5 24.9

Central Serbia 415 383 50.0 44.8 34.0

Employment status

Employed 411 435 49.0 44.3 33.2

Unemployed 177 166 53.7 50.2 40.9


Financial situation

Low 165 153 52.3 46.8 39.8

Medium 383 385 47.0 40.8 32.4

High 207 223 48.5 43.9 34.5

Future behaviour

Will vaccinate 651 653 40.7 34.4 27.2



Will not vaccinate 8 8 100 100 86.2


Table 6.3.6 – Vaccine-related risks, breakdown by demographics, % of agree answers (4+5)

91Research Findings


I am

wor

ried

that

chi

ldre

n ar

e ex

pose

d to

vac

cine

s to

o ea

rly

I am

wor

ried

abou

t the

qu

ality

of t

he v

acci

nes

I am

wor

ried

that

my

child

can

ge

t dis

ease

if n

ot v

acci

nate

d

I am

wor

ried

abou

t the

po

ssib

le o

utbr

eaks

of v

acci

ne

prev

enta

ble

dise

ases

I am

wor

ried

abou

t the

co

nseq

uenc

es o

f mor

e pa

rent

s re

fusi

ng to

va

ccin

ate

thei

r chi

ldre

n

All i

n al

l the

vac

cina

tion

is u

sefu

l

vacc

inat

ion

shou

ld b

e m

anda

tory

Ther

e sh

ould

be

lega

l co

nseq

uenc

es fo

r par

ents

who

re

fuse

to v

acci

nate

thei

r chi

ldre

n

I am

hes

itatin

g to

vac

cina

te m

y ch

ild b

ecau

se it

is m

anda

tory

30.9 46.5 77.0 68.0 66.2 84.0 72.2 40.3 17.8

17.2 29.2 100 95.0 78.5 100 100 50.2 0.0

31.0 46.7 76.8 67.8 66.0 83.9 71.9 40.2 18.0

32.3 50.1 76.5 65.9 66.1 83.5 74.0 38.5 15.4

29.7 43.7 77.4 69.8 66.2 84.5 70.7 41.7 19.7

13.7 25.4 72.0 59.0 67.3 78.0 78.1 53.8 21.0

34.0 48.6 78.3 70.9 64.7 85.7 73.0 40.6 16.1

31.5 50.8 76.5 66.0 68.5 83.2 68.1 34.4 20.0

33.6 48.0 75.8 69.6 66.9 81.6 68.5 38.3 18.6

26.1 44.0 79.2 65.2 64.8 88.3 78.6 43.8 16.3

48.4 56.3 72.8 69.4 66.3 79.3 66.1 39.7 22.8

21.4 35.7 83.1 64.4 63.7 89.6 77.6 54.1 18.4

27.6 47.6 75.8 69.3 67.4 83.3 72.2 33.4 15.1

29.6 48.8 78.7 72.2 67.6 86.4 71.9 43.9 17.1

40.0 48.5 72.4 64.7 68.2 79.6 71.1 30.7 15.2

26.2 41.0 77.5 63.3 62.0 83.3 73.5 41.2 21.0

34.0 47.6 70.1 61.8 62.8 77.8 66.8 38.0 24.6

31.9 46.0 79.1 69.7 66.7 85.7 75.4 41.4 16.5

27.5 45.3 76.2 67.7 65.3 86.5 71.7 40.6 16.3

21.7 38.4 81.4 69.4 68.1 91.5 81.7 46.5 12.3

59.7 68.3 70.7 73.3 70.3 67.3 47.1 21.5 27.2

74.0 92.4 53.3 47.5 46.5 41.8 21.8 12.7 66.0

86.2 100 0.0 0.0 20.4 23.4 0.0 0.0 73.0


There are visible differences in the perception of risks and benefits from vaccination be-tween vaccine supporters and hesitant parents: while supporters of vaccination primarily worry because of possible outbreak of vaccine-preventable diseases and refusal of other parents to have their children vaccinated, hesitant parents worry about the side effects of vaccines (79%), quality of vaccines (74%), dynamics of vaccine administration (too much 58%, too early 63%). However, the same group of parents is worried about an outbreak of vaccine-preventable diseases (66%), and they agree to a higher level than they disagree with the statement that vaccination is useful – this ambivalence in the attitudes indicates that it is necessary to pay more attention to communication with this segment of the popu-lation, and that it is still possible to influence their opinion. It also indicates that this group of parents is “vulnerable” to messages of both sides. On the other hand, supporters of vac-cination are more worried that their children would get a disease if not vaccinated (81%), about outbreaks of a vaccine preventable disease (69%) and about the consequences of more parents refusing to vaccinate their children (68%). Expectedly, more parents who ful-ly support vaccination state that vaccines are useful (92%), and that vaccination should be mandatory (82%).

93Research Findings

Figure 6.3.7 – Assessment of risks and benefits from vaccination, comparison between supporters ofvaccination and hesitant parents, % of agree answers (4+5)

I am worried that side effectsof vaccines.

49%41%

79%

I am worried that vaccines can triggerother diseases.

44%34%

77%

I am worried about the multiplevaccines in one take.

34%27%

58%

I am worried that children are exposedto vaccines too early.

31%22%

63%

I am worried about quality of thevaccines that are being administeredto my child.

47%38%

74%

I am worried that my child can getdisease if not vaccinated.

77%81%

66%

I am worried about possible outbreaks of vaccine preventable diseases.

68%69%

67%

I am worried about the consequencesof more parents refusing to vaccinatetheir children.

66%68%

65%

All in all the vaccination is useful.84%

92%61%

According to my opinion, vaccinationshould be mandatory.

72%82%

41%

I am hesitating to vaccinate my childbecause it is mandatory.

18%12%

37%

40%47%

19%

There should be legal consequences for parents who refuse to vaccinatetheir children.

Note: Scale from 1 (I don’t agree at all) to 5 (I completely agree)Total HesitantsSupporters


In focus group discussions, parents with positive attitude towards immunization pointed out numerous advantages of it: prevention of epidemics, precaution, psychological sta-bility, protection of the child and the whole society. For them, main disadvantages at the moment are: A) negative propaganda against vaccination, and no clear information or denial from professional public; B) absence of guaranteed protection from diseases after vaccination; C) absence of uniform attitude of medical workers towards vaccina-tion, so respondents have heard of medical workers who oppose vaccination, which addi-tionally disturbs parents from general population.

Parents with negative attitude towards vaccination have different attitude. Those who have given some vaccines to their children say that major advantages are collective im-munity and rooting out of diseases. Parents with extremist attitude see no benefits in vaccination. The perceived disadvantages primarily refer to the existing legal frame that stipulates compulsory vaccination, fines for not doing so, no information about vac-cines, about the composition of vaccines, about the fact that vaccines are imported, and proof that vaccines are simply neither beneficial nor good. Some of these parents, especially those who are having doubts about vaccination in the future, criticize the lack of positive propaganda about vaccination and its benefits. Also, their negative at-titude is strongly determined by the number of compulsory vaccines, including revac-cination. Many consider this number too big and many don’t believe that this is necessary, thinking that this schedule is forced by the interests of healthcare institutions and pharmaceutical companies. Giving MMR vaccines is a specific issue – many parents wonder why this vaccine can’t be postponed until child starts to talk.

According to many parents with positive attitude towards vaccines, vaccination should be compulsory in Serbia – because of growing number of parents who oppose vaccination, and to prevent epidemics. In line with their initial attitude towards vaccination, parents from focus groups, have different opinions regarding vaccinating children with compul-sory vaccines. While parents who support vaccination believe that all vaccines are neces-sary, parents with negative attitude towards vaccination share an opposite attitude. These parents believe that a significant problem is the very schedule of immunization and the number of vaccines children are to receive at the youngest age. The biggest problem at this moment is provoked by MMR vaccine, which majority of parents who oppose vaccination consider unnecessary. These parents either believe that there is a connection between this vaccine and autism or they are simply not sure about this, so they choose to avoid this vaccine until it becomes clear whether this connection exists. Those parents with the most extreme attitude against vaccination and those who haven’t vaccinated their children, strongly oppose application of BCG vaccines right after birth, without asking the parents. Such rules make these parents suspicious and mistrustful, because they believe something is kept hidden from them. Some who are planning to have more children are even thinking about the ways to prevent giving of BCG vaccines to their future children. Finally, some parents who oppose vaccination are quite suspicious about the origin of vaccines, given that they don’t have much confidence in import-ed vaccines.

95Research Findings

6.3.5. Vaccine-related myths – general population Vaccine-related myths were assessed by a scale consisting of thirteen Lickert type state-ments (inspired by Kata, 2011) assessing the endorsement of myths related to vaccina-tion (e.g. Vaccine against MMR causes autism. Preservatives in the vaccines are toxic; It is better for a child to overcome the disease and thus strengthen immunity than to be vaccinated; All measles are essentially harmless). The myths were chosen following the content analysis of the media and responses of parents in the focus groups. The state-ments were assessed on a five point scale, from 1-“completely disagree” to 5- “complete-ly agree”. The data were segregated to present the percentage of respondents who an-swered 4 and 5.

Myths related to vaccination are not widely accepted in the general population. However, it is worth noting that almost one third of parents believes that imported vaccines are of poor quality (32%) and that their quality is not properly controlled (33%). Similar share of parents believes that too many vaccines hamper children’s immunity (26%), that it would be better if children were older when vaccinated (27%) and that medicine today can cure diseases prevented by vaccines more successfully than side effects of immunization (30%). Only small percentage of parents agree that MMR causes autism (15%), that vac-cine preservers are toxic (16%), that measles are actually harmless (15%), that it is better for a child to overcome a disease and strengthen its immunity rather than to be vaccinat-ed (16%) or that vaccine preventable diseases are mild diseases (11%).

Although we did not register radical differences in endorsing vaccine-related myths, once again they were less endorsed by the less educated parents and more endorsed by par-ents from Belgrade, and unemployed parents. The group of hesitant parents who will give only some vaccines to their children agreed with a number of myths, including the one that MMR causes autism (57%) and that preservers in vaccines are toxic (57.6%), and even “All measles are harmless” (42%), and “Medicine can more easily cure vaccine prevent-able diseases than it can cure adverse vaccination reactions” (49%).


N N u

nw

Vacc

ine

agai

nst M

MR

ca

uses

aut

ism

Pres

erva

tives

in th

e va

ccin

es a

re to

xic

Com

bina

tion

vacc

ines

ar

e on

ly m

arke

ting

trick

of

pha

rmac

y se

ctor

824 824 15.1 18.1 26.3

GenderMale 8* 9* 17.2 0.0 0.0

Female 816 815 15.0 18.3 26.5


More than 30 y. 454 465 16.1 18.6 23.6

Education

Primary or less 97 61 8.3 12.9 23.1

Secondary 483 469 15.5 16.5 27.6

Faculty 244 294 16.9 23.4 24.8


Rural 299 278 10.1 14.6 26.0

Region

Belgrade 194 215 21.5 26.5 34.7

Vojvodina 215 226 12.0 14.2 19.5

Central Serbia 415 383 13.6 16.3 25.8

Employment status

Employed 411 435 16.1 17.9 23.6

Unemployed 177 166 17.0 20.8 31.5


Financial situation

Low 165 153 14.1 19.3 28.7

Medium 383 385 13.8 18.6 27.2

High 207 223 15.1 16.0 22.4

Future behaviour

Will vaccinate 651 653 8.9 12.1 19.2




Table 6.3.7 – Beliefs in vaccine-related myths, breakdown by demographics, general population


97Research Findings

The

vacc

ines

impo

rted

in

Serb

ia a

re o

f low

er q

ualit

y.

The

qual

ity c

heck

of t

he im

porte

d va

ccin

es is

not

goo

d en

ough

It is

bet

ter t

o w

ait f

or th

e ch

ild

to b

e ol

der a

nd to

stre

ngth

en,

and

then

vac

cina

te it

All v

iral “

rash

” dis

ease

s ar

e es

sent

ially

har

mle

ss

The

dise

ases

that

are

m

anda

tory

to v

acci

nate

ag

ains

t are

mild

dis

ease

s

Ther

e is

no

real

dan

ger o

f an

out

brea

k of

the

vacc

ine

prev

enta

ble

dise

ases

in S

erbi

a.

Mode

rn m

edici

ne ca

n mor

e eas

ily cu

re

disea

ses t

hat c

an be

prev

ented

by

the va

ccine

than

it ca

n cur

e unw

anted

co

nseq

uenc

es of

vacc

inatio

n

Too

man

y va

ccin

es a

re g

iven

to

the

child

ren

and

this

will

ham

per m

y ch

ild’s

imm

unity

It is b

etter

for t

he ch

ild to

over

come

the

dise

ase a

nd th

us st

reng

then

immu

nity,

rathe

r tha

n bein

g vac

cinate

d

Onl

y th

e fir

st d

ose

of v

acci

ne

is im

porta

nt, o

ther

dos

es (r

e-va

ccin

atio

n) a

re o

ptio

nal

32.0 33.3 27.2 14.7 011.6 19.0 30.1 25.9 16.0 9.9

0.0 12.0 17.2 0.0 0.0 15.7 52.0 17.2 0.0 0.0

32.4 33.5 27.3 14.9 11.7 19.0 29.9 25.9 16.2 10.0

33.0 33.2 26.2 15.6 10.3 20.4 32.1 23.6 13.9 10.7

31.3 33.4 28.0 14.1 12.6 17.8 28.5 27.7 17.7 9.2

24.0 19.3 15.3 15.5 13.0 30.5 18.4 14.6 9.7 8.0

32.6 34.0 27.3 14.7 12.1 17.3 32.1 27.2 17.5 11.6

34.1 37.3 31.7 14.4 10.1 17.6 30.9 27.6 15.5 7.3

32.7 35.0 29.4 15.0 11.2 17.4 29.2 28.8 15.6 10.5

31.0 30.3 23.4 14.3 12.4 21.7 31.7 20.6 16.8 8.8

41.1 45.8 39.5 10.2 15.9 20.4 38.7 36.2 26.8 11.9

25.0 26.4 16.3 14.9 6.8 18.0 21.8 16.8 13.3 7.3

31.5 31.0 27.1 16.8 12.1 18.9 30.4 25.8 12.3 10.3

32.2 33.2 28.1 13.6 8.9 16.1 30.4 26.8 16.0 9.4

34.9 33.3 31.5 19.1 20.9 26.1 35.3 28.6 19.2 10.8

29.6 33.4 22.4 13.4 9.3 18.6 25.7 22.1 13.6 10.1

35.9 38.4 24.4 13.0 10.3 19.8 31.0 24.9 13.9 11.4

31.6 31.2 29.1 13.5 12.5 18.1 34.0 25.3 15.4 9.8

28.4 33.3 26.2 17.8 11.2 18.4 23.1 26.8 18.0 7.9

25.0 24.7 17.0 11.5 8.3 16.8 26.9 17.4 10.6 7.7

50.3 57.3 64.2 19.1 18.2 24.7 41.2 49.6 25.0 16.2

68.6 78.5 71.5 42.0 35.6 31.1 49.1 73.0 54.9 22.3

100 100 79.4 65.2 51.4 49.2 61.5 86.2 78.1 17.6



Majority of myths related to vaccination aren’t widely accepted either among supporters of vac-cination (the share of 4 and 5 answers varies from 7.7% to 26.9%), which was expected, or among hesitant parents (the share of 4 and 5 answers varies way more in this subpopulation, from 17.7% to even 66%). Some myths are more widespread than others – for example, that it is better to wait until the child gets stronger and vaccinate him-her then (17% of supporters and 66% of hesitant), and that more vaccines administered in one take can weaken child’s im-mune system (17.4% of supporters and 55.3% of hesitant). Besides that, there is doubt relat-ed to quality (25% of supporters and 54.8% of hesitant) and control (24.7% of supporters and 62.5% of hesitant) of imported vaccines. The least widespread and accepted are the myths that minimise the risk of the disease that these vaccines prevent – “all measles are harmless”, “dis-eases prevented by vaccines are mild”, and “it is better to overcome the disease naturally than get vaccinated”.

The fact is, however, that a relatively significant share of parents exhibit dramatic lack of knowledge regarding the principles of vaccination, the need to follow the vaccination cal-endar and vaccine preventable diseases. Our results map the topics that need to be ad-dressed in public communications or communications with health officials.

As for the myths examined in focus groups discussions, the strongest ones are those relat-ed to MMR vaccine. MMR vaccines surely provoke most serious worry at the moment and everything mentioned seems to obstruct influencing such citizens’ perception. Parents with negative attitude toward vaccination have strong, negative attitude towards MMR vaccine, which is considered to be a lot more harmful than beneficial, primarily because of the supposed connection with autism. For those parents who are still having doubts about vaccines, a significant question is why MMR can’t be postponed, or why it has to be in-jected before child speaks – this is the reason why some parents deliberately postpone giving this vaccine. Furthermore, parents with negative attitude towards vaccination state that MMR vaccine is forbidden in some countries, which supports their doubts in the benefits of this vaccine. The attitude of health institutions and relevant bodies towards this issue is unclear, so there is no positive communication of professional public that may stimulate positive attitude of parents towards this vaccine.

Also, the attitude towards mechanisms for control of vaccine quality is largely influ-enced by the general attitude of parents towards the health system in Serbia. Negative at-titude is present even among parents who have vaccinated their children, and these par-ents also seem to lack information about the mechanisms of control, which would make their attitude more positive. Quite expectedly, parents with negative attitude to-wards vaccination also don’t trust to the mechanisms of vaccine control.

It is quite interesting that all parents share significantly more positive attitude towards lo-cal over imported vaccines. Parents state that they are a lot more suspicious about the im-port process, the way these imported vaccines are stored and the way producer of vac-cine is selected. The attitude towards Torlak certainly used to be more positive in the past, and even parents with negative attitude towards vaccination state that they had no doubts while Torlak produced vaccines. As for foreign vaccines, there is no single attitude about the preferred country for import of vaccines – respondents mention Germany and Russia, while they have somewhat more negative attitude towards vaccines from America. Moreover, this is not a topic parents talked about to paediatricians or other medical staff.

99Research Findings

Figure 6.3.8 – Belief in myths about the vaccination, comparison between supporters of vaccination andhesitant parents

Vaccine against MMR causes autism.15%

9%36%

Preservatives in the vaccines are toxic(poisonous).

18%12%

38%

Combination vaccines are onlymarketing trick of pharmacy sector.

26%19%

49%

The vaccines imported in Serbia areof lower quality.

32%25%

55%

The quality check of the importedvaccines is not good enough.

33%25%

63%

It is better to wait for the child to beolder and to strengthen, and thenvaccinate it.

27%17%

66%

All viral “rash” diseases are essentiallyharmless.

15%12%

25%

The diseases that are mandatory tovaccinate against are mild diseases.

12%8%

22%

There is no real danger of an outbreakof the vaccine preventable diseasesin Serbia.

19%17%

26%

Modern medicine can more easily curediseases that can be prevented bythe vaccine than it can cure unwantedconsequences of vaccination.

30%27%

43%

Too many vaccines are given to thechildren and this will hamper mychild’s immunity.

26%17%

55%

16%11%

32%

It is better for the child to overcomethe disease and thus strengthen immunity, rather than being vaccinated.

8%10%

18%

Only the first dose of vaccine is important, other doses (revaccination)are optional.

Note: Scale from 1 (I don’t agree at all) to 5 (I completely agree)



6.3.6. Vaccine-related conspiracy theories – general populationEndorsement of vaccine-related conspiracy theories was assessed by a scale (adapted from Shapiro et al., 2016), consisting of seven Lickert type statements assessing the en-dorsement of vaccine-related conspiracy theories (e.g. Pharmaceutical companies cover up dangers of the vaccines; Vaccine efficacy data is often fabricated). The statements were anchored with 1 (do not agree at all) and 5 (agree completely). The data were segregated to present the percentage of respondents who answered 4 and 5.

We analysed specific health related conspiracy theories. Hesitant parents are more likely to believe in conspiracy theories about vaccines than supporters of vaccination, and these differences are systematically registered on all questions. 31% of hesitant parents some-what or completely agree with the statements that vaccine safety is often fabricated (com-paring to only 16% of supporters), 31% agree with the statement that immunizing children is harmful and this fact is covered up (comparing to only 6% of supporters), 56% agree that pharmaceutical companies cover up dangers of vaccines (comparing to 17% of support-ers), 45% agree that people are deceived about vaccine safety (comparing to 12% of sup-porters), 33% of hesitant parents agree that vaccine efficacy is often fabricated (comparing to 11% supporters), 52% of hesitant parents agree that government is trying to cover up

Figure 6.3.9 – Theories of conspiracy regarding the vaccination, comparison between supporters of vaccination and hesitant parents

Vaccine safety data is often fabricated.20%

16%31%

Immunizing children is harmful andthis fact is covered up.

13%6%

31%

Pharmaceutical companies cover updangers of the vaccines.

26%17%

56%

People are deceived about vaccinesafety.

20%12%

45%

Vaccine efficacy data is oftenfabricated.

16%11%

33%

The government is trying to cover upthe link between vaccines and autism.

21%13%

52%

Domestic vaccines are better thanimported.

31%30%

35%

Note: On the scale from 1 (Certainly not) to 5 (Certainly yes)Total HesitantsSupporters

101Research Findings

the link between vaccines and autism (comparing to only 13% of supporters). However, it is worth mentioning that hesitant parents are also mainly indecisive when they have to evalu-ate the statements about cover-up of vaccine risks, while the supporters adamantly discard this. The only fact that both groups of parents moderately agree on is that domestic vac-cines are better than imported ones – it seems that this is a widespread belief and that it is coupled with lower confidence in institutions in charge of quality control.

6.3.7. Support of the surrounding and social norms concerning vaccination – general populationSocial norms about vaccination are very important; parents rely on different groups in making their health decisions. We asked about perceived support to immunization from several important groups: family, close friends, health providers, other parents, media, and religious beliefs. The data were segregated presenting the groups that somewhat support and absolutely support vaccination.

Majority of parents (90%) see health providers as greatest supporters of immunization, but also state that their family (80%) and close friends (70%) support it. However, it is believed that other parents support vaccination to a smaller extent (58%), while less than half of parents and only one third of Central Serbia residents recognized the me-dia as an instance supporting immunization (46%). It is important to mention that most important groups for vaccination, close family and health providers, support vaccination the most. When it comes to sociodemographic differences, only 38% of younger parents see the media as supporters of immunization, parents from rural areas are more likely to perceive support of religious leaders and other parents, close friends from Vojvodina are more likely to be perceived as supporting vaccination, while in Central Serbia media is less likely to be perceived as supporting vaccination, comparing to Vojvodina


N N u

nw

Fam

ily

Clo

se fr

iend

s

Hea

lth p

rovi

ders

Oth

er p

aren

ts

Med

ia

My

relig

ious

bel

iefs

824 824 80.3 69.8 89.5 57.9 45.8 54.8

Gen

der Male 8* 9* 95.0 95.0 100 84.0 79.1 66.7

Female 816 815 80.2 69.6 89.4 57.6 45.5 54.7

Age

cate

gory Up to 30 y. 370 359 78.7 65.7 87.5 54.8 38.3 54.5

More than 30 y. 454 465 81.6 73.1 91.2 60.5 52.0 55.1

Educ

atio

n Primary or less 97 61 79.2 65.4 91.0 57.7 45.8 64.1

Secondary 483 469 80.7 70.9 89.8 57.7 45.6 57.7

Faculty 244 294 80.1 69.5 88.5 58.3 46.4 45.6

Type

of

settl

emen

t

Urban 525 546 76.8 66.4 89.0 52.4 44.0 49.0

Rural 299 278 86.6 75.7 90.6 67.6 49.1 65.1

Reg

ion

Belgrade 194 215 74.0 65.1 89.9 53.6 54.8 52.8

Vojvodina 215 226 87.8 81.3 93.7 64.3 57.8 57.9

Central Serbia 415 383 79.4 66.1 87.3 56.6 35.5 54.2

Empl

oym

ent

stat

us

Employed 411 435 80.6 72.5 90.4 55.9 47.6 55.4

Unemployed 177 166 76.5 65.5 90.0 58.5 43.0 52.8

Housewife/Pensioner/Student 236 223 82.7 68.4 87.8 61.0 44.9 55.5

Fina

ncia

l si

tuat

ion

Low 165 153 77.2 65.8 84.8 54.8 49.4 48.2

Medium 383 385 83.0 70.5 92.9 61.4 43.9 57.5

High 207 223 78.3 71.6 88.6 59.6 48.8 53.6

Futu

re b

ehav

iour Will vaccinate 651 653 89.1 78.3 92.4 64.4 46.1 62.7

Probably will vaccinate 113 111 64.5 52.2 84.0 40.6 42.3 29.1

Will give some vaccines 37 37 16.0 12.6 76.5 19.1 58.4 13.4

Will not vaccinate 8* 8* 9.5 46.4 13.8 45.2 12.6

Table 6.3.8 – Social support for vaccination, breakdown by demographics

*Note: N<25, data is not analysed.


However, there are differences in perceived support between vaccine supporters and hes-itant parents. As expected, hesitant parents report lower levels of support for vaccination from family, friends, health providers and other parents. We cannot speak of causality in this case – it can be that hesitant parents impact their surrounding or are impacted by their sur-rounding; most probably, it is a two-way interaction.

It is interesting to note that both hesitant parents and vaccine supporters equally assess the level of media support to immunization as the lowest (46%).

Figure 6.3.10 – Social support for vaccination, comparison between supporters of vaccination and hesitant parents

Family80%

89%53%

Close friends70%

78%43%

Healthcare workers90%92%

82%

Other parents58%

64%35%

Media46%46%46%

My religion beliefs55%

63%25%

Note: Scale from 1 absolutely oppose to 5 absolutely supportTotal HesitantsSupporters

Parents believe that various social groups that can influence their attitudes – direct ones (family, close friends) and professionals – mainly support vaccination. The difference be-tween supporters and hesitant parents is registered most of all when they evaluate the sup-port of their immediate environment and attitudes of other parents. It is interesting that both groups evaluate the level of media support for vaccination as relatively low (46%) , which points to mixed and unsynchronised messages that the media send about this topic. On the other hand, both groups agree that medical workers mainly support vaccination very strongly.

Speaking about the support of the surrounding in decision making regarding vaccination, in focus group discussions, it was pointed out that numerous parents, even those with pos-itive attitude towards vaccination, report of their strong doubts about vaccination. The decision to vaccinate their child is usually made together with their spouse. Parents


who haven’t vaccinated their children say that this decision was easy, guided by their mistrust in vaccines, although some found it hard to make this decision, which was discussed for long and extensively with many family members.

Many parents have consulted their paediatrician in order to resolve their doubts about vaccination. Some paediatricians support vaccination openly, while others take neutral attitude, saying that parents have the right to decide whether they will vaccinate their children or not. Those with negative attitude towards vaccination also say that some medical workers told them how they wouldn’t vaccinate their children or that they were not sure what to recommend to parents.

Finally, the media, the internet, but also examples of people whose children got sick after receiving a vaccine, usually some form of autism after MMR vaccine, influence parental decisions. Although not all trust the media to an equal extent, many consider personal ex-periences of other people crucial for the direction of their decision.

6.3.8. Assessment of benefit from vaccination for community – general populationParents’ perception of vaccination benefits for the community was measured with three questions: By vaccinating my child I am contributing to the health and welfare of my society; Getting your child vaccinated is expected behaviour from families like mine, and If I don’t vaccinate my child that would make me an irresponsible parent. The data were segregated by the percentage of those who answered that they somewhat or completely agreed (an-swers 4+5).

Hesitant parents agree less with this set of statements than vaccine-supporters: only half of them (50.9%) agree completely or somewhat with the statement “By vaccinating my child I am contributing to the health and welfare of my society”, comparing to 84.5% of support-ers. While 83.7% of supporters agree with the statement “Getting your child vaccinated is expected behaviour from families like mine”, only 56.2% of hesitant agree with it. 74.8% of supporters agree with the statement “If I don’t vaccinate my child that would make me an ir-responsible parent”, while it is the case with only 35% of hesitant parents.Figure 6.3.11 – Assessment of vaccination benefits for the community, comparison between supporters ofvaccination and hesitant parents

66%75%

35%

77%84%

56%

76%85%

51%


If I don’t vaccinate my child that wouldmake me an irresponsible parent.

Getting your child vaccinated isexpected behavior from familieslike mine.

By vaccinatting my child I amcontributing to the health andwelfare of my society.



Judging by the answers of the total population respondents, vaccination of children is per-ceived as a norm, it is expected from responsible parents and it contributes to welfare of community. However, on all questions, significant differences are registered between par-ents who support vaccination and hesitant parents; the difference is particularly striking when it comes to whether parents who do not have their child vaccinated are irresponsible parents. Keeping in mind other attitudes which we tested among hesitant parents, it seems that they see themselves as informed, responsible and concerned – both regarding the con-sequences of non-vaccination, and consequences of vaccination.

6.3.9. Sources of information – general populationSources of information were measured asking about frequency of consuming different me-dia sources for health related issues (such as TV, newspapers, radio, official internet sites, forums, blogs, social media, ….), and asking about confidence in all media sources that are used on a five point scale. The data were segregated by the percentage of those who an-swer that they often or always use the following sources, or that they trust them (answers 4+5).

There are no striking demographic differences when it comes to media consumption for health-related issues. Better educated parents from general population use official Internet sites and forums/blogs more. Majority of parents (67%) receive information about vaccina-tion from health providers. About 22% use TV, Internet sites (26%) or social media (19%) to inform themselves about vaccination. About 12% use printed media and forums and blogs (18%) while only 3% use the radio. Parents with low education level use all media to a low-er extent while parents with high education use Internet and forums/blogs to a significantly greater extent. Above average percentage of parents from Belgrade rely on printed media.


N N u

nw

TV New

spap

ers.

prin

t med

ia

Rad

io

Offi

cial

Inte

rnet

site

s

Foru

ms.

blo

gs

Soci

al m

edia

Hea

lth p

rovi

ders

Frie

nds.

fam

ily m

embe

rs.

othe

r par

ents

824 824 21.6 12.1 3.2 26.0 17.7 18.7 67.4 61.1

Gen

der Male 8* 9* 3.6 0.0 0.0 20.3 20.3 32.3 95.0 60.6

Female 816 815 21.8 12.2 3.3 26.1 17.6 18.5 67.1 61.1

Age

cate

gory Up to 30 y. 370 359 21.0 10.7 3.9 28.1 18.9 19.3 67.9 60.5

More than 30 y. 454 465 22.1 13.3 2.7 24.3 16.6 18.2 66.9 61.7

Educ

atio

n Primary or less 97 61 22.9 5.6 1.1 18.8 6.6 7.1 59.4 54.1

Secondary 483 469 20.6 10.6 3.0 22.3 15.6 18.2 70.0 62.0

Faculty 244 294 23.0 17.6 4.7 36.4 26.1 24.1 65.3 62.1

Type

of

settl

emen

t

Urban 525 546 22.6 14.8 3.6 28.1 18.3 18.6 63.7 60.0

Rural 299 278 19.7 7.3 2.6 22.4 16.6 18.7 73.8 63.0

Reg

ion

Belgrade 194 215 26.0 21.1 4.9 31.3 22.0 21.1 71.1 64.6

Vojvodina 215 226 16.8 7.3 2.5 25.8 16.4 14.5 64.9 55.4

Central Serbia 415 383 22.0 10.4 2.9 23.7 16.3 19.7 66.8 62.4

Empl

oym

ent

stat

us

Employed 411 435 21.0 14.4 4.9 26.1 15.9 19.5 69.4 63.2

Unemployed 177 166 25.7 10.8 2.2 22.6 18.8 20.7 66.3 64.3


Fina

ncia

l si

tuat

ion

Low 165 153 22.7 14.9 2.5 20.1 14.9 16.1 64.6 60.5

Medium 383 385 20.9 9.7 3.2 27.4 17.6 18.4 69.4 62.2

High 207 223 24.4 14.3 3.8 29.1 21.1 19.9 62.6 58.8

Futu

re b

ehav




Will not vaccinate 8* 8* 16.6 25.2 0.0 20.6 17.6 40.6 43.7 100

Table 6.3.9 – Media consumption for health-related issues, breakdown by demographics, general population

*Note: N<25, data is not analysed.


Vaccine-hesitant parents are more likely than supporters of vaccination to consume all types of media, but the difference is particularly striking in case of Internet – both official websites (42%) and informal ones (forums, blogs 28% and social networks 31%). Supporters of vac-cination report that they consult medical workers more frequently, 72%. This can be inter-preted by the fact that hesitant parents are more proactive and independent in searching for information, while supporters of vaccination predominantly rely on official authorities.

As expected, hesitant parents have less confidence in majority of proposed sources of in-formation than supporters of vaccination do. This is particularly the case with the tradition-al media, while this group trusts informal sources of information somewhat more, such as social networks (41% of hesitant). 38% of supporters have confidence in TV, comparing to 31% of hesitant; 33% of supportive parents have confidence in newspaper comparing to 23% of hesitant. However, these differences are not striking, and both groups claim to have the highest confidence in medical workers and their immediate environment (friends, family, other parents), 89% of supporters, and 72% of hesitant parents.

Figure 6.3.12 – Frequency of consumption of various media, comparison between supporters of vaccinationand hesitant parents

TV22%

19%33%

Newspapers, print media12%11%

17%

Radio3%3%4%

Official Internet sites26%

23%42%

Forums, blogs18%

15%28%

Social media19%

16%31%

Health providers67%

72%50%

Note: Scale from 1 (Never) to 5 (Always)Total HesitantsSupporters


In focus group discussions, parents with positive attitude towards vaccination also point out that their paediatricians are the main sources of information about vaccination. But, on the other hand, communication with them is perceived differently.

Some say that paediatricians are interested in providing information about vaccines, while others disagree and believe that paediatricians are not educated and interested enough. Parents with positive attitude towards vaccination trust paediatricians, while parents with negative attitude towards vaccination don’t trust anyone or trust people with experience with vaccination - those with negative experience first of all. Besides paediatricians, parents also consult other parents about this, their close ones, but they also browse the internet, fo-rums and social networks. Internet consumption is especially frequent among parents with negative attitude towards vaccination.

Figure 6.3.13 – Trust in various media, comparison between supporters of vaccination and hesitant parents

36%38%

31%

30%33%

23%

34%38%

27%

58%61%

50%

44%45%44%

36%34%

41%

84%89%

72%

Note: Scale from 1 (Not at all) to 5 (Completely) Total HesitantsSupporters

TV

Newspapers, print media

Radio

Official Internet sites

Forums, blogs

Social media

Health providers


6.3.10. Media literacy – general populationMedia literacy. A scale consisting of six Lickert type statements about the “critical” me-dia consumption (e.g. I am searching for different sources of the same information on the Internet; I take into consideration whether the author of the text has an interest to represent a certain viewpoint). The statements were anchored with 1 (never) and 5 (always). The data is segregated by the % of parents who said frequently and always.

Hesitant parents seem to more critically consume the media in comparison to vaccine-sup-porters. They more often claim to be searching for the author of the text (27%), search-ing for different sources of information (47%), thinking about the author of the text (34%). However, half of them also report that they only pick up basic information and discuss them with friends (51% versus 35% among supporters of immunization) or just read the title of the text (21% among hesitant versus 16% among supporters).

Figure 6.3.14 – Media literacy, comparison between supporters of vaccination and hesitant parents

I am searching for the authorof the text.

20%18%

27%

I am searching for different sourcesof the same information on the Internet.

36%34%

47%

I am thinking if the author of the text has an interest to representa certain viewpoint.

30%28%

34%

I „pick up” basic information anddisuss them with friends.

38%35%

51%

I read the title – the text is anywaymere repetition of the title.

17%16%

21%

I am capable of reading the newsonly in my native language.

17%17%19%


Internet consumers in Serbia do not have the habit to critically question the news on the Internet, search for the authors of the texts, different sources of the same news, or read the news in other languages. Hesitant parents are somewhat more likely to have a critical ap-proach towards internet, but the differences are mainly small. One must be cautious with interpretation of these findings since parents (particularly the supporters of vaccination) ex-press lower confidence in Internet as a source of information, so we cannot claim that they accept everything that they read on it uncritically. On the other hand, digital information ir-reversibly takes precedence over traditional media, so it is important to keep up with the trends in the digital media literacy - in time, media literacy will really become a filter helping to distinguish reliability of information.


6.3.11. Preferred channels of communication about vaccination – general populationPreferred communication tools. Respondents were asked how they would like to receive information about the vaccines. They were given eight options (e.g. Written brochures in health centres that can be taken home; Posters in health centres that can be read while waiting; Websites offering a possibility to pose online questions to paediatricians, immunol-ogists, more time to talk to their paediatrician) and answered with Yes/No. Presented data refers to % of YES responses.

Although both groups of parents state that they want to be informed about vaccination and they mainly accept all proposed channels of communication, the impression is that support-ers of vaccination find written materials in health institutions (brochures 86%, posters 80%) more suitable, while the group of hesitant parents would find interactive materials more ap-pealing (parents’ forums 65%, websites which allow readers’ questions 76%). Both groups would like to have more time for conversation with their paediatrician (73% supporters, and 75% hesitant).

Figure 6.3.15 – Media literacy, comparison between supporters of vaccination and hesitant parents

Written brochures in health centersthat can be taken home.

83%86%

74%

Posters in health centers that can beread while waiting.

78%80%

74%

A telephone line that can be calledfor vaccine-related questions.

74%74%76%

TV debates on vaccination withexperts.

68%67%

72%

Parental forums, blogs.53%

50%65%

Websites offering a possibilityto pose online questions to pediatricians, immunologists etc...

Parenting seminars (“Škole roditeljstva”) to address vaccination.

More time allowed to spend talking to my pediatrician.

70%69%

76%

63%63%64%

72%73%75%



Parents in focus group discussion state that professionals, representatives of higher instances, the Ministry of Health for instance, but also doctors, are directly responsible for providing more information about vaccination. All parents say that they would like to know more about quality of vaccines, composition of vaccines and have a clear list of adverse effects, with focus on MMR and its connection with autism. The preferred methods for obtaining additional information about vaccines for all parents from general population except those with strongly negative attitude are: promotional materials, brochures, media programs, but also or-ganized lectures within Parent Counselling services, or health centres.

6.3.12. Confidence in medical authorities – general populationRespondents assessed their trust in nine different institutions or treatment methods (e.g. paediatrician, nurse, health system, alternative medicine, official medicine). They used a five-point scale anchored with 1 (I don’t trust at all) to 5 (I completely trust). Present data re-fers to those who stated that they somewhat and completely trust (4+5).

Figure 6.3.16 – Confidence in medical authorities, comparison between supporters of vaccination andhesitant parents

Your pediatrician in healt center82%

89%61%

Your pediatrician in the privatesector (if you have one)

30%31%

24%

Nurses (medical stuff other thandoctors)

70%77%

49%

Healt system in Serbia53%

58%35%

Pharmaceutical industry43%

47%27%

National Agency for Quality Controlof Medicines and Vaccines

Alternative medicine (homeopathy,acupuncture, Reiki and similar)

Tradicitional medicine (herbal teas,ointments and similar)

Official medicine

47%51%

36%

Note: Scale from 1 (I don’t trust at all) to 5 (I completely trust)

41%41%42%

71%71%

68%

79%84%

62%



The picture of public opinion when it comes to confidence in health authorities is rather en-couraging: 82% of parents trust their paediatricians (89% of supporters, and 61% of hesi-tant) and official medicine (79%). Supporters are more likely (84%) to trust official medicine comparing to hesitant (62%). Confidence in institutions connected with production (43%) and quality control of drugs (47%) is somewhat lower, particularly among hesitant parents (as for hesitant parents, 36% have confidence in the national agency for quality control, and only 27% in pharmaceutical industry).

6.3.13. Trust in science – general populationRespondents assessed their attitude towards modern science through four statements (e.g. I am amazed by the achievements of modern science; I think that science will find the cure for most currently incurable diseases in the future.). The statements were anchored with 1 (do not agree at all) and 5 (agree completely). The data presented bellow represent the per-centage of those who somewhat agree or completely agree.

68% of parents express high level of trust in science, despite the small differences between hesitant parents and parents who support vaccination. 70% of supporters and 67% of hes-itant parents are amazed by the achievements of modern science. Hesitant parents are more likely to suspect the motives of scientists (37%) and scientific method as the only re-liable way to discover the truth about the world (only half of hesitant parents think that the scientific method is the only reliable way of finding out the truth about the world).

Figure 6.3.17 – Confidence in medical authorities, comparison between supporters of vaccination and hesitant parents

I am amazed by the achievementsof modern science.

68%70%

67%

I think scientific method is the onlyreliable way of finding the truth about the world.

61%63%

51%

I doubt in the motives of scientistsnowadays.

28%26%

37%

I think that science will find the curefor most currently incurable diseasesin the future.

77%79%

72%



6.4. Report from the quantitative and qualitative research - Roma population

6.4.1. Vaccination related behaviour – Roma populationWhen looking at the Roma parents sample, the percentage of parents who state that they took a child to vaccination as per the immunization calendar is somewhat lower (85%) than in general population. There are 6% of parents who claim that they were hesitant or that they delayed vaccination, while 5% didn’t give all mandatory vaccines to their child. Percentage of those who didn’t vaccinate their children at all (4%) is higher than in the gen-eral population.

Figure 6.4.1 – Previous behaviour related to child’s vaccination

85%

6%

5%4%

% who were hesitant, but still vaccinated

% who vaccinated their children according to schedule

% who allowed only some vaccines

% who refused vaccination completely

Looking at the Roma parents’ past vaccination related behaviour, there were no statistical-ly significant differences as per sociodemographic variables that were monitored. Younger parents from Roma population were somewhat more hesitant in the past (8%), and were more likely to allow only some vaccines (6%).


N N u

nw

sig

% v

acci

nate

d th

eir c

hild

% w

ho w

ere

hesi

tant

. bu

t stil

l vac

cina

ted

% w

ho a

llow

ed o

nly

som

e va

ccin

es

% w

ho re

fuse

d va

ccin

atio

n co

mpl

etel

y

210 209 84.9 6.4 4.9 3.8

Gen

der Male 2* 2*

1.00100 0.0 0.0 0.0

Female 207 207 84.7 6.4 5.0 3.8

Age

cate

gory Up to 30 y. 153 162

0.5484.0 7.9 6.1 2.1

More than 30 y. 56 47 87.4 2.3 1.8 8.4

Educ

atio


0.99

83.4 7.0 5.4 4.2

Secondary 18 14 100 0.0 0.0 0.0

Faculty 0** 0** 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 153 1440.93

84.6 6.9 5.5 3.0

Rural 56 65 85.8 4.9 3.3 6.0

Reg

ion

Belgrade 39 40

0.52

93.8 2.6 0.0 3.7

Vojvodina 31* 26* 100 0.0 0.0 0.0

Central Serbia 139 143 79.0 8.9 7.4 4.7

Empl

oym

ent

stat

us

Employed 14* 12*

0.93

71.2 9.2 9.8 9.8

Unemployed 113 112 82.4 6.6 7.1 3.9


Fina

ncia

l si

tuat

ion

Low 138 138

0.82

80.8 6.6 6.8 5.8

Medium 46 47 95.0 3.0 2.0 0.0

High 21* 21* 86.2 13.8 0.0 0.0

Futu

re b

ehav


0.46

92.0 5.6 1.3 1.0


Will give some vaccines 3* 3* 33.4 0.0 66.6 0.0

Will not vaccinate 3* 2* 0.0 0.0 0.0 100

Table 6.4.1 – Past vaccination related behaviour, breakdown by demographics

*:N<25, data is not analysed. **: No data.


In focus groups discussions, all Roma parents point out that their children are vaccinated with mandatory vaccinations. When it comes to the experiences with delay of vaccination, Roma parents, similar to parents from general population with positive attitude toward vac-cination, state that they postpone vaccination due to sickness of their children. Also, Roma fathers stated that they forgot to vaccinate their children, but they were contacted by repre-sentatives of health centres, and after that they took their children to vaccination.

As for parents’ intention to vaccinate children in the future, the situation is somewhat different in Roma population compared with the general population: same percentage of parents will definitely comply with the vaccination calendar (85%), but the percentage of those who would probably vaccinate increased to 9%. Percentages of parents who will re-fuse certain vaccines (2%) and who will not vaccinate their children at all (2%) decreased in comparison to past behaviour.

There are no significant differences between groups of Roma parents as per the observed background variables; the percentage of hesitant parents is somewhat higher in urban than in rural settlements (7% in urban settlements vs. 5% in rural settlements) and among par-ents under 30 (8%). In the future, there will be more of hesitant parents coming from bet-ter-off families, even in the Roma sample (14%).

Figure 6.4.2 – Future vaccination behaviour

85%

9%

2%

2%

% who will probably follow the shedule

% who will certainly follow the shedule

% who will refuse some vaccines

% who will refuse to get child vaccinated at all


N N u

nw

sig

I will

certa

inly g

et him

/her v

accin

ated

follow

ing th

e sch

edule

.

I will

prob

ably

get h

im/he

r vac

cinate

d fol

lowing

the s

ched

ule.

I will

get h

im/he

r vac

cinate

d for

some

va

ccine

s. an

d refu

se th

e othe

rs.

I will

refus

e to g

et him

/he

r vac

cinate

d at a

ll.

Don't

know

. refu

sal

211 211 85.3 9.3 1.7 1.6 2.2

Gen

der Male 2* 2*

1.0055.8 44.2 0.0 0.0 0.0

Female 209 209 85.6 8.9 1.8 1.6 2.2

Age

cate

gory Up to 30 y. 154 163

0.8586.8 7.8 2.4 0.9 2.1

More than 30 y. 57 48 81.1 13.1 0.0 3.5 2.3

Educ

atio


1.00

84.6 9.4 1.9 1.8 2.4

Secondary 18* 14* 92.4 7.6 0.0 0.0 0.0

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 1451.00

86.1 9.5 2.4 0.0 2.0

Rural 57 66 83.0 8.6 0.0 5.9 2.4

Reg

ion

Belgrade 39 40

0.99

89.0 11.0 0.0 0.0 0.0

Vojvodina 31 26 100 0.0 0.0 0.0 0.0

Central Serbia 140 145 80.9 10.8 2.6 2.4 3.2

Empl

oym

ent

stat

us

Employed 14* 12*

0.95

63.3 17.1 0.0 9.8 9.8

Unemployed 113 113 84.0 11.0 1.6 1.8 1.6


Fina

ncia

l si

tuat

ion

Low 139 139

1.00

83.4 10.3 1.3 2.4 2.6

Medium 47 48 86.9 11.2 2.0 0.0 0.0

High 21* 21* 91.0 0.0 4.5 0.0 4.5

Futu

re b

ehav


0.00

100 0.0 0.0 0.0 0.0


Will give some vaccines 4* 4* 0.0 0.0 100 0.0 0.0


Table 6.4.2 – Future vaccination related behaviour, breakdown by demographics



6.4.2. Experiences, attitudes and behaviour of Roma parents: comparison between parents hesitant and supportive of vaccinationWe present the results for the whole population of Roma parents; on certain questions we also present demographic breakdown, and we compared Roma parents supportive of vac-cination ad vaccination hesitant Roma parents. Data collected only on Roma population are clearly marked. For aggregating data, we used the same strategy as for the general pop-ulation. Namely, for Yes-No questions, the percentage of “Yes” answers is given, while for questions where the respondents used an agreement scale, we give the sum of positive an-swers on the Likert scale (e.g. 4 plus 5 on a 5-point scale).

When it comes to analysis of answers of Roma population, we must bear in mind the scien-tific findings (Elijaš & Laklija, 2014) on their propensity towards socially desirable answers. Therefore we should be cautious in interpretation of results – they can be biased by respon-dents’ assumptions on what is expected of them, and their perception of the widespread social norms.

6.4.3. Previous experience with vaccination of the youngest childRoma population did not report of any widespread barriers to vaccination. Almost all men-tioned barriers to vaccination were reported by less than 10% of Roma parents.

The greatest barrier for Roma parents (10%), regarding vaccination, was to follow the schedule (vaccination calendar), with no statistical differences between different socio-de-mographic groups. Roma parents from urban areas almost never complained about the dis-tance from the health centre, whilst almost 13% residents of urban areas mentioned this as a barrier.


N N u

nw

I too

k th

e ch

ild t

o th

e va

ccin

atio

n fo

llow

ing

the

cale

ndar

I was

invi

ted

by p

hone

I rec

eive

d w

ritte

n no

tice

to c

ome

203 205 72.0 13.1 30.5

GenderMale 2* 2* 100 0.0 0.0

Female 201 203 71.7 13.2 30.8


More than 30 y. 52 45 84.1 13.4 33.8

Education

Primary or less 185 191 72.2 13.6 29.2

Secondary 18* 14* 69.8 7.6 43.6

Faculty 0** 0** 0.0 0.0 0.0


Rural 54 64 68.2 31.1 46.7

Region

Belgrade 38 39 100 14.0 12.5

Vojvodina 31 26 97.1 14.5 26.0

Central Serbia 134 140 58.2 12.5 36.6

Employment status

Employed 13* 11* 59.9 8.9 19.8

Unemployed 109 110 69.6 9.1 30.6


Financial situation

Low 131 133 73.1 13.8 31.0

Medium 47 48 69.7 12.0 29.5

High 21* 21* 64.2 9.4 36.2

Future behaviour

Will vaccinate 178 179 75.2 12.7 31.9

Probably will vaccinate 18* 19* 53.1 16.4 17.8

Will give some vaccines 4* 4* 50.0 25.1 24.9

Will not vaccinate 0** 0** 0.0 0.0 0.0


Table 6.4.3 – Experiences with vaccination, breakdown by demographics



paed

iatri

cian

info

rmed

me

abou

t the

nex

t im

mun

izat

ion

I was

n’t a

nsw

ered

my

ques

tion

I was

giv

en th

e im

mun

izat

ion

cale

ndar

I wai

ted

long

er th

an h

alf a

n ho

ur

ther

e w

ere

no v

acci

nes

avai

labl

e

child

was

exa

min

ed

befo

re v

acci

natio

n

I was

info

rmed

abo

ut th

e pu

rpos

e of

the

vacc

ine

I was

info

rmed

abo

ut

adve

rse

effe

cts

he in

form

ed u

s ho

w to

re

act t

o ad

vers

e ef

fect

s

Chi

ld h

ad a

mild

reac

tion

Chi

ld h

ad a

stro

ng re

actio

n

gene

rally

pos

itive

82.8 8.5 76.7 26.8 13.9 95.4 78.7 87.2 90.7 57.7 4.4 95.4

100 0.0 55.8 55.8 0.0 100 44.2 100 55.8 55.8 0.0 100

82.6 8.6 76.9 26.5 14.1 95.4 79.1 87.1 91.1 57.7 4.5 95.4

83.1 7.1 76.8 25.2 14.0 96.0 75.9 84.7 90.2 51.4 4.2 95.6

81.8 12.5 76.4 31.3 13.8 93.7 86.7 94.5 92.2 75.9 5.0 95.0

83.7 7.0 78.2 24.4 14.3 96.8 77.3 87.5 90.5 56.1 4.9 95.0

74.0 23.9 61.4 51.4 10.0 81.6 92.8 84.8 92.4 73.8 0.0 100

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

83.0 4.1 75.3 26.8 14.5 97.3 76.3 87.4 91.5 58.4 5.0 94.8

82.1 20.8 80.4 26.9 12.3 90.2 85.5 86.7 88.4 55.7 2.9 97.3

87.5 6.4 85.6 16.3 3.8 100 88.2 100 96.2 61.2 000 97.3

82.9 3.3 100 14.7 2.9 100 97.1 91.4 100 38.3 5.7 100

81.4 10.3 68.7 32.6 19.4 93.1 71.7 82.6 87.0 61.3 5.4 93.9

69.4 10.9 52.1 36.3 0.0 89.1 78.9 89.1 81.0 65.0 8.1 91.9

76.6 9.3 74.7 28.0 6.9 95.6 84.6 87.9 91.6 53.6 5.0 92.5

93.1 7.1 83.2 23.7 25.6 96.1 70.8 86.0 91.0 62.1 3.1 100

79.9 8.1 75.2 28.0 8.2 93.6 82.0 88.3 91.7 59.5 5.5 93.6

85.7 12.1 86.2 24.0 19.7 98.0 75.6 85.3 88.9 59.5 2.0 98.1

90.6 4.5 63.8 22.6 40.8 100 59.8 82.1 86.6 41.7 4.5 100

85.7 6.5 80.6 25.8 14.1 96.1 80.8 88.6 94.5 57.6 5.1 98.0

60.4 26.2 51.8 31.5 18.2 94.9 72.6 86.2 67.5 65.3 0.0 78.6

100 24.9 50.0 75.1 0.0 100 49.9 50.0 50.0 24.9 0.0 75.1

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0


Even though the experience with vaccination is generally evaluated positively both by general and Roma population, Roma population report (85%) even more positive expe-riences (98% of vaccine supporters claim to have had positive experience with vaccina-tion, versus 78% of hesitant Roma parents). Despite highly positive experiences, only 72% of Roma parents took a child to vaccination on their own following the immuniza-tion calendar (compared with 88% in general population). It is obvious that the health system is making efforts to increase immunization coverage of Roma as almost one third of Roma received written notification to bring their children to immunization (25% of parents from urban areas and 47% from rural areas were invited through a written notification). One third of Roma parents from rural areas was invited through a phone call from a health facility. On some questions, we did not register the differences in ex-periences between supportive and hesitant parents: almost all Roma parents claim that their paediatrician examined the child before vaccination and a very small percentage reported severe reactions to vaccination. Most differences between the two clusters were noticeable in their assessment of communication with health officials: 52% of hes-itant parents say that their paediatrician informed them about the date of the next vac-cination in comparison to 81% of supporters; 65% of hesitant parents say their paedia-trician instructed them how to react in case of adverse reactions in comparison to 95% of vaccine-supportive Roma parents.


Figure 6.4.3 – Experience with vaccination, comparison between Roma parents hesitant and supportiveof vaccination


I took a child to vaccination followingthe vaccination calendar.

72%75%

53%

I was called on the phone by the healthofficials when my child needed to bevaccinated.

13%13%

18%

I received a written notification onmy address from the health officialsinforming me that my child neededto be vaccinated.

31%32%

19%

I had a question about vaccines thatI did not get an answer to.

83%86%

67%

I was given vaccination calendar ina healthcare institution.

9%7%

26%

My child’s pediatrician informed meabout the next date for vaccinationmy child needs to receve.

77%81%

52%

I waited for a long time (more thanhalf an hour) for a vaccine in thehealth center.

27%26%

39%

There were no vaccines in the healthcenter.

14%14%15%

My child was examined by pediatricianfor health status before vaccination.

95%96%96%

My child’s pediatrician informed meabout the disease my child is gettingvaccinated against.

79%81%

69%

My child’s pediatrician informed meabout potential side-effects from thevaccine.

87%89%

80%

My child had a mild adverse reaction(swelling, temperature) to vaccine that cleared quickly and did not require anymedical...

91%95%

65%

My child had a severe adverse reactionto vaccine that needed to be treatedmedically and reviewed and reported by...

58%58%59%

In general, my experience wihvaccination was positive.

4%5%

My child’s pediatrician instructed mehow to react in case my child gets any adverse reaction.

95%98%

78%


Parents from Roma population who participated in focus group discussions pointed out their satisfaction with services and staff of health institutions. The only thing that they report more frequently are experiences with medical workers who didn’t want to examine a child– it usually happens when they miss their doctor’s shift, so then they return home without completing their intended task.

Majority of Roma parents who participated in focus groups state that they haven’t been invited by health centres for vaccination of children, but that they have heard of other mem-bers of their community who were invited because they missed to vaccinate their chil-dren. In their words, health mediators are recognised as very important in this domain, as they often visit households together with doctors who vaccinate children on the spot. There are a lot more reports about such cases out of Belgrade. On the other hand, as men-tioned before, Roma fathers say that they have been invited by phone and in writing to bring their children for vaccination, because they were late.

When it comes to immunization calendar and immunization booklets, all Roma focus group participants state that they have immunization booklets, which they use to adhere to the time for vaccination, and they say that paediatricians talk to them about vaccination during health check-ups. On the other hand, they are not so much familiar with the schedule of re-vaccination - mothers are better informed than fathers are. Some say that revaccination doesn’t take place at all, and that child gets new vaccine every time.

When it comes to past experiences with vaccination, similar to parents from general popu-lation, Roma parents remember periods when vaccines weren’t available. They remember that in 2013-2014. there was a shortage of vaccines and that they had to wait for 6 months for them. However, they don’t know which vaccine this was. In addition, some of these par-ents were offered to buy Pentaxim before it became compulsory – some purchased this vaccine, others waited until it became available in health centres.

Also, Roma parents are more likely than parents in general population to report about be-ing afraid while their children received vaccines. They were afraid of the consequences because of the growing rumours about harmfulness of vaccines, but none of them reported about adverse reactions to vaccines.


Figure 6.4.4 – Vaccination campaign in Roma settlements

Was there ever a campaign forvaccination in your community?

Have you vaccinated any of yourchildren as a result of vaccinationcampaign in your community?

10,9%

68%

Figure 6.4.5 – Vaccination campaign in Roma settlements, comparison between supporters of vaccinationand hesitant parents

Was there ever a campaign forvaccination in your community?

Have you ever vaccinated any of yourchildren as a result of vaccinationcampaign in your community?

11%

18%

68%

67%

HesitantsSupporters

6.4.3. Specificities of Roma population: the campaign in settlements, experiences of discrimination in health institutionsIn the previous period, there were several state-supported campaigns aimed to increase vaccination coverage among Roma children. Some 11% of Roma parents recall such cam-paigns and 68% of them claim that their children were vaccinated within those campaigns. Hesitant Roma parents are somewhat more likely to recall the campaigns and their children were affected by campaigns to the similar extent as the overall Roma population.


Experiences of extreme discrimination by the health system are not so common, or at least Roma respondents do not often report such experiences. It happens very rarely (5% of cases) that paediatricians refuse to treat a Roma child or express negative attitudes towards Roma parents accusing them of being bad parents (7%). However, almost one third of Roma parents experienced uncomfortable situations - 34% reported that they had to wait long23, while 28% of parents claim that doctors or nurses were rude to them or their children. Every fifth parent complained that s/he was spoken to in a manner that was not understandable. No systematic socio-demographic differences were registered. Hesitant Roma parents are more likely to report discrimination experiences on all parameters, which might have affected their confidence in the general health system.

23 The question on waiting time was asked twice (as a part of their overall experience with immunization and specifically to Roma popu-lation on their perception of discrimination) and the share of parents who responded positively is different and bigger when this question was asked within the set of question exploring perception of discrimination.

Figure 6.4.6 – Experiences with discrimination in healthcare system

7%

22%

35%

5%

28%

I was told by the the doctor ornurses that I am not a good parent.

I was spoken in a manner thatI did not understand.

I was left to wait longet thanthe odhers.

Doctors or nurses refused to treatmy child.

Doctors or nurses were rude to meor my child.


N N u

nw

Doc

tors

or n

urse

s w

ere

rude

to m

e or

my

child

Doc

tors

or n

urse

s re

fuse

d to

trea

t my

child

.

I was

left

to w

ait l

onge

r th

an th

e ot

hers

.

I was

spo

ken

to in

a m

anne

r th

at I

did

not u

nder

stan

d.

I was

told

by

doct

ors

or n

urse

s th

at I

am n

ot a

goo

d pa

rent

.

211 211 28.3 4.8 34.6 21.9 6.9

Gen

der Male 2* 2* 0.0 0.0 0.0 0.0 0.0

Female 209 209 28.6 4.9 35.0 22.2 7.0

Age

cate

gory Up to 30 y. 154 163 28.3 5.7 33.2 22.2 6.9

More than 30 y. 57 48 28.3 2.5 38.5 21.3 6.9

Educ

atio

n Primary or less 193 197 30.3 5.3 34.7 23.5 7.6

Secondary 18 14 7.6 0.0 33.6 5.0 0.0

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 30.8 5.7 35.2 23.7 5.7

Rural 57 66 21.5 2.5 33.2 17.0 10.1

Reg

ion

Belgrade 39 40 21.4 5.0 27.6 18.6 6.2

Vojvodina 31 26 11.4 5.7 17.1 25.8 0.0

Central Serbia 140 145 34.0 4.6 40.5 22.0 8.7

Empl

oym

ent

stat

us

Employed 14* 12* 26.1 0.0 16.3 0.0 26.7

Unemployed 113 113 23.6 6.9 36.4 15.5 7.1


Fina

ncia

l si

tuat

ion

Low 139 139 31.0 3.7 39.8 24.3 9.9

Medium 47 48 17.7 3.0 28.2 13.0 2.0

High 21* 21* 40.4 13.2 17.6 22.1 0.0

Futu

re b

ehav

iour Will vaccinate 180 181 23.1 4.4 30.7 21.8 2.9

Probably will vaccinate 20* 20* 45.3 7.1 65.0 26.4 14.5

Will give some vaccines 4* 4* 100 25.1 24.9 50.0 50.0

Will not vaccinate 3* 2* 58.8 0.0 58.8 0.0 100

Table 6.4.4 – Experiences with discrimination in healthcare system, breakdown by demographics



Roma parents do not identify any systemic barrier for vaccination: the only relatively wide-spread one is the claim that obtaining medical ID was difficult (22%). Some 10% claim that they did not vaccinate their children because they were not certain of what to do and when. Some barriers seem to be more prominent for Roma parents from rural areas. Similar to the previous questions, no significant demographic differences emerged.

Figure 6.4.7 – Experiences with discrimination in healthcare system, comparison of supporters of vaccinationand hesitant parents

21%3%

30%22%

58%

9%

31%

4%

54%23%

I was told by doctors or nurses thatI am not a good parent.

I was spoken in a manner thatI did not understand.

I was left to wait longet thanthe odhers.

Doctors or nurses refused to treatmy child.

Doctors or nurses were rude to meor my child.

HesitantsSupporters



N N u

nw

My ch

ild ha

s a m

edica

l ID

It was

(is) d

ifficu

lt to g

et me

dical

IDs f

or m

y chil

d

I cou

ld no

t get

the ch

ild va

ccina

ted on

time

beca

use I

had n

o one

to le

ave o

ther c

hildr

en.

I cou

ld no

t get

the ch

ild va

ccina

ted on

time b

ecau

se

I was

n’t su

re w

hat I

was s

uppo

sed t

o do a

nd w

hen

I cou

ld no

t get

the ch

ild va

ccina

ted on

tim

e bec

ause

I for

got a

bout

it.

I cou

ld no

t get

the ch

ild va

ccina

ted on

time b

ecau

se th

e me

dical

care

centr

e is h

ard f

or m

e to r

each

(too

far).

I cou

ld no

t get

the ch

ild va

ccina

ted on

time b

ecau

se

there

was n

o one

to ac

comp

any m

e to t

he he

alth c

entre

.

I cou

ld no

t get

the ch

ild va

ccina

ted on

time b

ecau

se

trans

port t

o the

healt

h care

centr

e is t

oo ex

pens

ive fo

r me.

I cou

ld no

t vac

cinate

the c

hild o

n tim

e bec

ause

the c

hild d

id no

t hav

e a m

edica

l. hea

lth re

cord

(or ha

d no c

hose

n doc

tor).

211 211 93.4 21.7 4.5 10.0 6.8 4.2 4.5 4.5 7.1

Gen

der Male 2* 2* 100 44.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Female 209 209 93.4 21.5 4.5 10.2 6.9 4.2 4.6 4.6 7.2

Age

cate

gory Up to 30 y. 154 163 92.8 18.8 2.7 9.8 6.4 2.1 3.6 3.6 6.9

More than 30 y. 57 48 95.2 29.5 9.2 10.8 7.8 9.7 6.9 6.9 7.6

Educ

atio

n Primary or less 193 197 93.3 21.1 4.9 10.5 7.4 4.6 4.9 4.9 6.6

Secondary 18 14 95.0 28.4 0.0 5.5 0.0 0.0 0.0 0.0 12.6

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 94.0 20.9 3.6 8.9 6.5 0.9 2.1 2.1 7.2

Rural 57 66 91.8 23.8 6.9 13.3 7.6 12.9 10.9 10.9 6.9

Reg

ion

Belgrade 39 40 95.0 11.2 3.7 12.4 8.8 3.7 3.7 3.7 7.5

Vojvodina 31 26 97.1 11.5 0.0 0.0 0.0 0.0 0.0 0.0 5.7

Central Serbia 140 145 92.2 26.9 5.7 11.6 7.7 5.2 5.7 5.7 7.3

Empl

oym

ent

stat

us

Employed 14* 12* 90.2 26.4 0.0 28.8 9.8 19.6 19.6 19.6 9.8

Unemployed 113 113 94.7 21.7 4.3 10.7 3.1 3.4 4.3 3.8 6.6

Housewife/Pensioner/Student 84 86 92.3 21.0 5.4 6.0 11.3 2.5 2.2 2.8 7.4

Fina

ncia

l si

tuat

ion

Low 139 139 95.3 23.2 6.1 13.6 7.9 6.3 6.8 6.8 7.1

Medium 47 48 92.2 17.2 2.0 04.9 7.0 0.0 0.0 0.0 6.9

High 21* 21* 82.1 26.9 0.0 0.0 0.0 0.0 0.0 0.0 9.0

Futu

re b

ehav

iour Will vaccinate 180 181 94.4 18.0 2.6 6.2 3.5 2.0 1.8 1.9 6.2

Probably will vaccinate 20* 20* 92.6 40.2 7.4 22.1 19.1 2.4 7.4 7.1 19.2

Will give some vaccines 4* 4* 74.9 25.1 0.0 25.1 25.1 0.0 0.0 0.0 0.0

Will not vaccinate 3* 2* 58.8 58.8 58.8 100 58.8 100 100 100 0.0

Table 6.4.5 – Systemic barriers to vaccination, share of response YES


Bigger share of hesitant Roma parents claim that they had difficulties obtaining health insur-ance card, that they didn’t have personal health record card, that they were not sure what they were supposed to do, or that they simply forgot about it. Therefore, this is a subgroup of parents with difficulties in interaction with the health system and they are unsure about the expected vaccination-related behaviour. Other physical or logical obstacles (money, dis-tance, care about other children) are mentioned significantly less often.

Figure 6.4.8 – System barriers for vaccination (answered only by Roma), comparison of supporters ofvaccination and hesitant parents

It was (is) difficult to get healthinsurance card for my child.

My child doesn’t have health insurance card.

6%9%

I could not get the child vaccinatedon time because I had no one toleave other children.I could not get the child vaccinated on time because I wasn’t sure whatI was supposed to do and when..

I could not get the child vaccinated on time because the medical care center is hard for me to reach (too far).I could not get the child vaccinated on time because there was no one to accompany me to the health center.I could not get the child vaccinated on time because transport to the health care center is too expenvice for me.I could not get the child vaccinated on time because the child did not have a medical, health record (orhad no chosen doctor).

I could not get the child vaccinated on time because I forgot about it.

18%39%

3%4%

6%22%

3%23%

2%0%

2%4%

2%4%

6%18%

HesitantsSupportersWith the following set of questions, we assessed the coverage and perceived quality of health mediators who were introduced as a system intervention to help Roma pop-ulations interact with the health system. Health mediators are active in a smaller number of Roma communities (just 16.8% of parents reported they had an active health mediator in their community). However, in communities in which they were visible, their work had posi-tive effect on the readiness to vaccinate children. They regularly visited families, reminding parents of the vaccination calendar and offering help with vaccination.


6.4.4. Roma parents’ knowledge and attitudes towards vaccinationWe assessed the vaccine related knowledge of Roma parents with the same seven ques-tions we tested the general population with. On average, Roma parents exhibited worse knowledge on vaccination than general population. The highest percentage of correct an-swers were registered for questions “Do you know what revaccination is?” (29%), and “Do you know the best timeline for vaccination?” (26%). Less than 1% knew correctly against which diseases MMR/DiTePer vaccines work, and which groups of children should not be immunized. There were no significant demographic differences, apart from respondents with secondary education and residents of Belgrade, scoring higher than the rest on a sin-gle question.

Figure 6.4.10 – Perception of activities of health mediators in the community (answered only by Roma),comparison between supporters of vaccination and hesitant parents

19%4%

56%0%

69%

74%

0%

100%

69%100%

There is a health mediator activeinour community.

I know the name of the healthmediator in our community.

The healt mediator regularly visits our family.

The health mediator reminds usabout the dates for vaccination.

The health mediator offers help toget children vaccinated.

Note: The first question is answered by all Roma respondents, while the following ones are answered by those who claim that there isa health mediator in their community.

HesitantsSupporters

Figure 6.4.9 – Perception of activities of health mediators in the community (answered only by Roma)

17%

55%

67%

73%

70%

There is a health mediator activeinour community.

I know the name of the healthmediator in our community.

The healt mediator regularly visits our family.

The health mediator reminds usabout the dates for vaccination.

The health mediator offers help toget children vaccinated.


N N u

nw

Do

you

know

how

vac

cina

tion

prot

ects

aga

inst

dis

ease

?

Some

grou

ps of

child

ren s

hould

NOT

be

immu

nized

. Wha

t gro

ups a

re th

ose

Do

you

know

aga

inst

whi

ch

dise

ase

is B

CG

vac

cine

?

Do

you

know

aga

inst

whi

ch

dise

ases

is M

MR

vac

cine

?

Do

you

know

aga

inst

whi

ch

dise

ases

DiT

ePer

vac

cine

?

Do

you

know

wha

t the

bes

t tim

elin

e fo

r the

vac

cina

tion

is?

Do

you

know

wha

t re

vacc

inat

ion

is?

All a

nsw

ers

are

corre

ct

in G

sec

tion

211 211 16.8 0.5 22.2 1.0 0.7 25.5 29.2 0.0

Gen

der Male 2* 2* 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Female 209 209 17.0 0.5 22.4 1.0 0.8 25.8 29.5 0.0

Age

cate

gory Up to 30 y. 154 163 13.7 0.7 19.2 0.7 0.7 26.1 25.2 0.0

More than 30 y. 57 48 25.4 0.0 30.4 2.0 1.0 24.1 40.2 0.0

Educ

atio

n Primary or less 193 197 16.7 0.5 19.5 1.1 0.8 23.0 25.6 0.0

Secondary 18* 14* 18.2 0.0 50.3 0.0 0.0 52.1 67.2 0.0

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 15.9 0.7 20.0 01.4 0.7 18.6 24.9 0.0

Rural 57 66 19.2 0.0 28.0 0.0 1.0 44.2 40.9 0.0

Reg

ion

Belgrade 39 40 17.9 2.6 26.6 5.5 4.0 36.2 53.1 0.0

Vojvodina 31 26 9.8 0.0 15.6 0.0 0.0 30.4 24.5 0.0

Central Serbia 140 145 18.1 0.0 22.4 0.0 0.0 21.5 23.6 0.0

Empl

oym

ent

stat

us

Employed 14 12 22.5 0.0 66.4 0.0 7.1 22.4 49.3 0.0

Unemployed 113 113 11.5 0.0 17.6 1.9 0.5 25.3 29.1 0.0


Fina

ncia

l si

tuat

ion

Low 139 139 13.7 0.0 19.9 1.5 01.1 24.0 26.0 0.0

Medium 47 48 23.3 2.1 32.7 0.0 0.0 33.8 40.1 0.0

High 21* 21* 26.8 0.0 18.3 0.0 0.0 9.4 18.9 0.0

Futu

re b

ehav


Probably will vaccinate 20* 20* 16.7 0.0 21.2 0.0 0.0 7.3 31.2 0.0

Will give some vaccines 4* 4* 0.0 0.0 0.0 0.0 0.0 25.1 25.1 0.0

3* 2* 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0


Table 6.4.6 – Share of correct answers on knowledge test, breakdown by demographics


Hesitant Roma parents scored worse than vaccine supporters on the knowledge test. If we compare their total results, more than half of the hesitant group (56%) did not answer to a single question correctly. Supporters were more numerous in the group with three correct answers (10.1 versus 4.3), and four correct answers (2.2 versus 0).

In focus group discussions, it is noticed that Roma parents show lower level of knowledge than parents from general population. They are less informed, especially Roma fathers, although many of them have heard of some of the consequences of avoiding vaccination. Speaking of epidemics, also not many focus group participants from Roma population were able to point out concrete ones in the past that were stopped with vaccines – many of them mention flu, but also swine and avian influenza.

6.4.5. Assessment of risks and benefits from vaccinationRoma parents are worried about the side effects of vaccination, but it doesn’t exceed the assessed positive effects of vaccination (40 % worry about the side effects of vaccines, but twice the number, 81%, worry about their child contracting vaccine preventable disease (VPD). Overall, Roma parents are more positive about vaccination in comparison to gen-eral population: 93% agree that “All in all, vaccines are useful”, 87% agree that vaccination should be mandatory, and less than one third are worried about vaccine quality or multi-ple vaccines in a single take. We registered almost no significant demographic differences, apart from single instances on particular questions.

Figure 6.4.11 – Total score on a knowledge test – comparison between Roma parents hesitant and supportive of vaccination

44%43%

57%

27%28%

17%

18%17%

22%

9%10%

4%

2%2%

0

1

2

3

4



N N u

nw

I am

wor

ried

abou

t the

si

de e

ffect

s of

vac

cine

s

I am

wor

ried

that

vac

cine

s ca

n tri

gger

oth

er d

isea

ses

I am

wor

ried

abou

t the

mul

tiple

va

ccin

es in

one

take

211 211 40.2 38.4 31.9

GenderMale 2* 2* 0.0 0.0 44.2

Female 209 209 40.6 38.9 31.8


More than 30 y. 57 48 40.0 36.4 24.4

Education

Primary or less 193 197 38.6 35.3 29.5

Secondary 18* 14* 56.7 71.2 56.8

Faculty 0** 0** 0.0 0.0 0.0


Rural 57 66 32.9 33.8 32.3

Region

Belgrade 39 40 28.1 21.2 21.8

Vojvodina 31 26 20.1 17.2 26.6

Central Serbia 140 145 48.0 48.0 35.9

Employment status

Employed 14* 12* 34.9 19.6 24.3

Unemployed 113 113 38.3 36.2 32.9


Financial situation

Low 139 139 36.5 34.3 29.1

Medium 47 48 41.1 35.7 33.5

High 21* 21* 67.8 59.1 45.1

Future behaviour

Will vaccinate 180 181 35.8 33.5 30.5


Will give some vaccines 4* 4* 100 75.1 49.9

3* 2* 58.8 58.8 0.0

Table 6.4.7 – Vaccine-related risks, breakdown by demographics



I am

wor

ried

that

chi

ldre

n ar

e ex

pose

d to

vac

cine

s to

o ea

rly

I am

wor

ried

abou

t the

qu

ality

of t

he v

acci

nes

I am

wor

ried

that

my

child

can

ge

t dis

ease

if n

ot v

acci

nate

d

I am

wor

ried

abou

t the

po

ssib

le o

utbr

eaks

of v

acci

ne

prev

enta

ble

dise

ases

I am

worri

ed ab

out th

e con

sequ

ence

s of

more

pare

nts re

fusing

to

vacc

inate

their c

hildr

en

All i

n al

l the

vac

cina

tion

is u

sefu

l

vacc

inat

ion

shou

ld b

e m

anda

tory

Ther

e sh

ould

be

lega

l co

nseq

uenc

es fo

r par

ents

who

re

fuse

to v

acci

nate

thei

r chi

ldre

n

I am

hes

itatin

g to

vac

cina

te m

y ch

ild b

ecau

se it

is m

anda

tory

29.0 30.4 81.3 70.1 44.9 92.5 86.9 57.7 14.5

44.2 44.2 44.2 100 0.0 55.8 55.8 0.0 0.0

28.8 30.3 81.7 69.7 45.4 92.9 87.2 58.4 14.7

31.0 30.5 80.9 70.0 44.9 92.8 86.4 59.0 16.6

23.5 30.2 82.4 70.2 44.7 91.7 88.1 54.3 8.9

27.1 28.3 81.6 69.7 43.0 91.8 86.4 58.8 15.4

48.6 53.3 77.9 74.0 64.1 100 92.4 46.6 5.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

29.9 32.2 83.7 73.5 41.8 93.9 89.0 53.0 14.8

26.6 25.8 74.7 60.8 53.3 88.8 81.2 70.6 13.6

19.3 10.4 87.6 64.0 31.2 100 97.4 62.4 5.8

11.6 14.7 97.1 65.6 41.4 100 90.6 61.5 17.4

35.6 39.5 76.0 72.7 49.5 88.8 83.1 55.6 16.3

26.9 46.7 71.2 70.6 38.8 65.8 65.8 15.2 7.3

28.2 25.0 76.0 61.3 37.4 93.2 83.6 54.9 15.2

30.4 35.1 90.1 81.8 56.0 96.1 95.0 68.9 14.8

27.5 26.9 79.4 65.5 39.7 92.0 84.6 55.9 18.7

23.0 31.5 86.5 77.1 44.6 93.9 88.6 58.2 1.9

54.7 40.8 91.0 77.9 72.8 91.0 95.5 77.6 17.9

25.8 26.9 86.0 71.8 47.4 97.5 92.7 63.5 13.4

45.3 48.9 61.0 65.6 33.9 90.0 73.5 31.9 14.1

74.9 74.9 74.9 100 50.0 25.1 25.1 0.0 50.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0


Figure 6.4.12 – Assessment of risks and benefits from vaccination, comparison between Roma parents hesitant and supportive of vaccination

40%36%

60%

38%34%

62%

32%31%

50%

29%26%

50%

30%27%

53%

81%86%

63%

70%72%71%

45%47%

36%

93%98%

80%

87%93%

66%

15%13%

20%

58%64%

27%

I am worried that side effectsof vaccines.

I am worried that vaccines can triggerother diseases.

I am worried about the multiplevaccines in one take.

I am worried that children are exposedto vaccines too early.

I am worried about quality of thevaccines that are being administeredto my child.

I am worried that my child can getdisease if not vaccinated.

I am worried about possible outbreaks of vaccine preventable diseases.

I am worried about the consequencesof more parents refusing to vaccinatetheir children.

All in all the vaccination is useful.

According to my opinion, vaccinationshould be mandatory.

I am hesitating to vaccinate my childbecause it is mandatory.

There should be legal consequences for parents who refuse to vaccinatetheir children.



As expected, and closely following the pattern in general population, hesitant Roma parents are more worried about risks of vaccination (60% versus 36% of supporters), vaccines trig-gering other diseases (62% vs 38%) multiple vaccines in a single take (50% versus 31%), and too many vaccines too early (50% versus 29%).

In focus group discussions, Roma parents were aware of vaccination benefits – they usually mentioned that it protects us from illnesses and from dying. On the other hand, they didn’t mention many disadvantages – they usually didn’t know the answer to this question.

In general, parents from Roma population have positive attitude towards vaccination, and they pointed out that they would recommend to other parents to vaccinate their children, because of prevention and better immunity.

Similar to majority of parents from general population, Roma parents agree that vaccina-tion should be compulsory in Serbia. They stated that child protection is the priority, even if it means forcing some parents by legal means.

6.4.6. Vaccine-related mythsIt is interesting that myths and misconceptions about vaccination are more present in gen-eral population than in Roma population. On average, less than 5% of Roma parents agree that MMR causes autism, only 6% that preservatives in vaccines are toxic. Even the most widespread myths are endorsed by less than half of Roma parents: Medicine can more eas-ily cure VPDs than vaccine side effects (40%); There is no real danger of VPD outbreak in Serbia (36%). Whether this is the result of the fact that Roma parents are less informed or indeed have higher confidence in the system remains to be explored further. Similar to pre-vious questions, we did not register any significant socio-demographic differences in en-dorsement of vaccine-related myths.

As expected, vaccine-hesitant Roma parents were more prone to vaccine-related myths in comparison to vaccine supporters. For example, only 4% of supporters believed in MMR-autism link in comparison to 12% of hesitant parents; 25% of supporters expressed concern that vaccines might hamper the immune system in comparison to 42% of hesitant parents.


N N u

nw

Vacc

ine ag

ainst

MMR

caus

es au

tism

Pres

erva

tives

in th

e vac

cines

are t

oxic

Comb

inatio

n vac

cines

are o

nly

marke

ting t

rick o

f pha

rmac

y sec

tor

211 211 4.9 6.3 7.4

GenderMale 2* 2* 0.0 0.0 44.2

Female 209 209 4.9 6.4 7.0


More than 30 y. 57 48 3.2 2.5 6.6

Education

Primary or less 193 197 3.4 6.5 6.9

Secondary 18* 14* 20.0 5.0 12.6

Faculty 0** 0** 0.0 0.0 0.0


Rural 57 66 0.9 3.3 2.4

Region

Belgrade 39 40 2.9 3.7 9.1

Vojvodina 31 26 0.0 0.0 0.0

Central Serbia 140 145 6.5 8.5 8.5

Employment status

Employed 14* 12* 0.0 0.0 14.4

Unemployed 113 113 5.0 6.1 10.0


Financial situation

Low 139 139 2.8 3.6 7.2

Medium 47 48 1.9 9.9 10.0

High 21* 21* 13.4 17.9 4.5

Future behaviour

Will vaccinate 180 181 4.2 4.6 5.2




Table 6.4.8 – Beliefs in vaccine-related myths, breakdown by demographics



The v

accin

es im

porte

d in

Serb

ia ar

e of lo

wer q

uality

.

The q

uality

chec

k of th

e imp

orted

va

ccine

s is n

ot go

od en

ough

It is b

etter

to w

ait fo

r the

child

to be

olde

r an

d to s

treng

then,

and t

hen v

accin

ate it

All v

iral “r

ash”

dise

ases

are

esse

ntiall

y har

mles

s

The d

iseas

es th

at ar

e man

dator

y to

vacc

inate

again

st ar

e mild

dise

ases

Ther

e is n

o rea

l dan

ger o

f an

outbr

eak o

f the v

accin

e pr

even

table

disea

ses i

n Ser

bia.

Mode

rn m

edici

ne ca

n mor

e eas

ily cu

re

disea

ses t

hat c

an be

prev

ented

by

the va

ccine

than

it ca

n cur

e unw

anted

co

nseq

uenc

es of

vacc

inatio

n

Too m

any v

accin

es ar

e give

n to

the ch

ildre

n and

this

will

hamp

er m

y chil

d’s im

munit

y

It is b

etter

for t

he ch

ild to

over

come

the

dise

ase a

nd th

us st

reng

then

immu

nity,

rathe

r tha

n bein

g vac

cinate

d

Only

the fir

st do

se of

vacc

ine

is im

porta

nt, ot

her d

oses

(re

vacc

inatio

n) ar

e opti

onal

13.6 20.2 26.6 19.0 10.4 35.7 39.7 24.7 15.8 6.5

44.2 44.2 44.2 0.0 44.2 0.0 100 100 44.2 0.0

13.2 20.0 26.4 19.2 10.1 36.1 39.0 23.8 15.5 6.5

15.0 18.6 27.8 19.7 9.8 34.0 38.6 23.9 16.7 5.6

9.7 24.7 23.5 17.1 12.2 40.5 42.6 26.7 13.5 8.7

12.4 18.7 26.0 16.9 9.9 33.0 36.9 23.1 14.9 7.1

26.0 36.0 33.6 40.8 15.8 64.7 69.0 41.2 26.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

13.6 22.2 27.6 22.5 13.0 35.7 37.6 27.1 14.1 6.9

13.4 14.9 24.2 9.4 3.5 35.8 45.5 18.0 20.4 5.2

6.2 15.3 24.3 13.1 8.0 51.0 45.0 20.5 10.8 0.0

6.2 14.4 14.4 5.7 0.0 31.0 12.0 9.0 0.0 8.6

17.3 22.9 30.0 23.6 13.4 32.5 44.4 29.3 20.8 7.8

7.3 14.6 44.0 17.1 7.3 39.0 55.9 33.6 34.2 7.3

17.4 21.3 26.8 21.1 8.6 39.0 36.5 25.4 19.1 6.3

9.5 19.8 23.5 16.4 13.5 30.8 41.3 22.2 8.3 6.5

13.1 21.3 28.2 13.8 7.5 28.2 36.7 24.6 20.0 9.1

12.1 15.8 26.1 22.9 14.9 53.3 52.0 22.3 4.2 2.0

23.4 27.4 22.9 31.7 22.4 37.0 40.7 31.7 17.9 0.0

10.7 19.3 24.5 19.4 11.7 38.7 41.6 20.6 11.8 6.7

29.1 26.8 33.9 4.7 5.3 24.8 41.2 36.1 19.4 8.1

74.9 50.0 50.0 25.1 0.0 25.1 25.1 74.9 49.9 0.0

0.0 0.0 41.2 58.8 0.0 0.0 0.0 58.8 100 0.0


Figure 6.4.13 – Beliefs in vaccine-related myths, comparison between Roma parents hesitant and supportiveof vaccination

5%4%

12%

6%5%

18%

7%5%

23%

14%11%

36%

20%19%

30%

27%25%

36%

19%19%

8%

10%12%

5%

36%39%

25%

40%42%

39%

25%21%

42%

16%12%

24%

7%7%

7%

Vaccine against MMR causes autism.

Preservatives in the vaccines are toxic(poisonous).

Combination vaccines are onlymarketing trick of pharmacy sector.

The vaccines imported in Serbia areof lower quality.

The quality check of the importedvaccines is not good enough.

It is better to wait for the child to beolder and to strengthen, and thenvaccinate it.

All viral “rash” diseases are essentiallyharmless.

The diseases that are mandatory tovaccinate against are mild diseases.

There is no real danger of an outbreakof the vaccine preventable diseasesin Serbia.

Modern medicine can more easily curediseases that can be prevented bythe vaccine than it can cure unwantedconsequences of vaccination.

Too many vaccines are given to thechildren and this will hamper mychild’s immunity.

It is better for the child to overcomethe disease and thus strengthen immunity, rather than being vaccinated.

Only the first dose of vaccine is important, other doses (re-vaccination)are optional.




Similar to parents from general population, Roma parents who participated in focus groups were very worried about the connection between MMR vaccine and autism. Many of them reported that they watched TV shows in which this was the topic, and that they were wor-ried about it after that.

Having in mind other myths, parents from Roma population don’t have clear attitude to-wards them and they don’t show extensive knowledge about this topic. In general, sim-ilar to parents from general population, they show more positive attitude towards do-mestic vaccines than towards imported vaccines. They are also against application of several vaccines at the same time.

6.4.7. Vaccine-related conspiracy theoriesRoma parents were less prone to vaccine-related conspiracy theories in comparison to par-ents from the general population. Hesitant Roma parents were somewhat more prone to conspiracy in comparison to vaccine supportive ones, however, not a single conspiratorial statement was endorsed by more than 30% of hesitant parents (with the exception of belief that domestic vaccines are of better quality than imported ones – one could debate if this should be viewed as a conspiratorial belief or not).Figure 6.4.14 – Conspiracy theories related to vaccination, comparison between Roma parents hesitantand supportive of vaccination

Vaccine safety data is often fabricated.12%11%

22%

Immunizing children is harmful andthis fact is covered up.

6%2%

24%

Pharaceutical companies cover updangers of the vaccines.

11%8%

28%

People are deceived about vaccinesafety.

12%8%

24%

Vaccine efficacy data is oftenfabricated.

6%4%

12%

The government is trying to cover upthe link between vaccines and autism.

8%6%

22%

Domestic vaccines are better thenimported.

32%37%

11%

Note: On a scale from 1 “Definitely not true” to 5 ”Definitely true”Total HesitantsSupporters


6.4.8. Perceived social support/social norms concerning vaccinationIn compliance with the previous findings, the data on social climate in general population, and in Roma population, show that general climate about vaccination is overall positive. Roma parents report that majority of groups in their environment (family, friends, medical workers, religious leaders), support vaccination strongly – (91% give 4 or 5 to family mem-bers, 95% to health providers, 82% to close friends). Roma parents view media as vac-cine-supportive (61% on average); however only half of Roma community leaders are per-ceived as supportive.


N N u

nw

Fam

ily

Clo

se fr

iend

s

Hea

lth p

rovi

ders

Oth

er p

aren

ts

Med

ia

My

relig

ious

bel

iefs

Rom

a co

mm

unity

lead

ers

211 211 90.9 81.7 94.7 70.3 60.8 76.2 50.4

Gen

der Male 2* 2* 100 100 100 0.0 44.2 55.8 0.0

Female 209 209 90.8 81.5 94.6 71.0 61.0 76.4 51.0

Age

cate

gory Up to 30 y. 154 163 91.3 82.8 94.0 74.4 58.3 73.2 50.0

More than 30 y. 57 48 89.9 78.8 96.5 58.9 67.7 84.1 51.5

Educ

atio

n Primary or less 193 197 90.1 80.7 95.6 69.9 61.4 76.8 49.8

Secondary 18 14 100 92.4 85.1 74.4 55.1 69.9 56.3

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 91.0 82.7 96.4 73.8 64.0 76.8 43.3

Rural 57 66 90.8 79.1 90.0 60.5 52.1 74.5 69.6

Reg

ion

Belgrade 39 40 96.3 4.5 100 88.0 77.1 100 34.9

Vojvodina 31 26 100 100 100 97.1 64.1 65.7 65.0

Central Serbia 140 145 87.4 74.1 92.0 59.3 55.5 71.9 51.4

Empl

oym

ent

stat

us

Employed 14* 12* 73.1 71.2 80.4 48.6 61.3 73.1 48.6

Unemployed 113 113 93.4 80.5 94.6 70.2 56.3 67.6 37.0

Housewife/Pensioner/Student 84 86 90.7 85.2 97.3 74.1 66.9 88.3 68.8

Fina

ncia

l si

tuat

ion

Low 139 139 89.6 77.9 95.2 67.3 61.0 72.8 45.9

Medium 47 48 96.1 93.2 98.0 73.0 63.1 91.0 53.4

High 21* 21* 86.6 77.2 95.5 77.2 59.3 73.4 63.0

Futu

re b

ehav

iour Will vaccinate 180 181 98.1 87.6 96.9 76.6 63.6 82.2 54.8

Probably will vaccinate 20* 20* 73.9 71.2 100 53.1 61.6 66.1 39.4

Will give some vaccines 4* 4* 0.0 0.0 74.9 0.0 50.0 0.0 0.0

Will not vaccinate 3* 2* 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Table 6.4.9 – Social support for vaccination, breakdown by demographics



Importantly, Roma parents who are hesitant to vaccinate perceive less support for vacci-nation in their immediate surroundings (62% family, 60% friends) in comparison to vaccine supporters (98% family, 88% friends). Both clusters see healthcare workers as vaccine sup-porters (more than 95%).

Similar to parents from general population, Roma population parents also report having doubts regarding vaccination. However, the decision to vaccinate a child was usually made with their partner – same as in case of parents from general population. They also state that their entire surrounding supports vaccination.

6.4.9. Assessment of vaccination benefits for the wider communityAlthough both Roma and general population perceive vaccination as a practice which sig-nificantly contributes to public health, assessment of benefits from vaccination is higher among Roma population than in general population. Reasons for that can be different: Roma parents may have a more realistic picture of vaccine preventable diseases than gen-eral population. Myths and conspiracy theories about vaccination have reached Roma pop-ulation to a lesser extent, so they see nothing controversial in it.

Family

Close friends

Healthcare workers

Other parents

Media

My religion beliefs

Figure 6.4.15 – Social support for vaccination, Roma parents hesitant and supportive of vaccination

91%98%

62%

82%88%

60%

95%97%96%

70%77%

45%

61%64%

60%

76%82%

56%

Note: Scale from 1 absolutely oppose to 5 absolutely supportTotal HesitantsSupporters


However, the actual vaccination coverage is smaller in Roma population in comparison to general population and Roma parents are exposed to vaccine related persuasion more. That could be the reason why 88%, on average, claim that vaccinating a child is behaviour expected from families like theirs, and 81% agree that non-vaccination is a sign of bad par-enting. Hesitant parents agree less with these statements (68% and 47% respectively).

6.4.10. Sources of information for health related issuesRoma parents claim that they are mainly informed about vaccination by health workers, which indicates that they are aware of the reliable sources. However, the second most fre-quently used source of information for are other parents or relatives. Roma, considerably less than general population, seek information in newspapers and considerably less use Internet in any form. No significant demographic differences in media consumption were registered.

Figure 6.4.16 – Assessment of benefits from vaccination for community, Roma parents hesitant andsupportive of vaccination

81%89%

47%

88%94%

68%

87%93%

68%

If I don’t vaccinate my child that wouldmake me an irresponsible parent.

Getting your child vaccinated isexpected behavior from familieslike mine.

By vaccinatting my child I amcontributing to the health andwelfare of my society.



N N u

nw

TV New

spap

ers.

prin

t med

ia

Rad

io

Offi

cial

Inte

rnet

site

s

Foru

ms.

blo

gs

Soci

al m

edia

Hea

lth p

rovi

ders

Frie

nds.

fam

ily m

embe

rs.

othe

r par

ents

211 211 21.5 01.5 1.1 7.0 3.4 6.0 71.3 43.1

Gen

der Male 2* 2* 44.2 0.0 0.0 44.2 0.0 0.0 55.8 0.0

Female 209 209 21.3 1.5 1.1 6.6 3.4 6.1 71.5 43.6

Age

cate

gory Up to 30 y. 154 163 18.9 1.2 1.6 6.7 1.5 5.2 71.4 42.7

More than 30 y. 57 48 28.8 2.3 0.0 7.9 8.4 8.4 71.1 44.3

Educ

atio

n Primary or less 193 197 19.9 1.2 1.2 5.4 2.6 5.6 71.2 44.7

Secondary 18* 14* 39.1 5.5 0.0 24.3 11.2 11.2 72.4 26.2

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 19.4 2.1 0.7 7.1 3.0 6.7 74.2 42.0

Rural 57 66 27.2 0.0 2.4 6.9 4.4 4.4 63.7 46.3

Reg

ion

Belgrade 39 40 19.6 2.6 2.6 8.8 3.7 8.8 50.8 47.5

Vojvodina 31 26 3.3 0.0 0.0 6.5 6.5 6.5 79.7 59.7

Central Serbia 140 145 26.1 1.6 1.0 6.6 2.6 5.2 75.2 38.2

Empl

oym

ent

stat

us

Employed 14* 12* 15.3 0.0 7.1 21.7 14.4 14.4 56.2 49.3

Unemployed 113 113 23.9 1.7 1.2 7.4 2.1 4.6 65.4 35.8


Fina

ncia

l si

tuat

ion

Low 139 139 24.1 1.7 1.7 3.7 1.9 3.3 66.5 38.4

Medium 47 48 23.5 2.0 0.0 18.6 7.4 13.4 81.9 48.5

High 21* 21* 4.5 0.0 0.0 4.5 4.5 8.9 86.6 63.8

Futu

re b

ehav





Table 6.4.10 – Frequency of various media consumption, breakdown by demographics



Same as in general population, vaccine hesitant Roma parents turn to health providers less, and use Internet and social networks for vaccine-related information more often than vac-cine supporters.

Frequency of media usage is correlated with the trust in them. Thus, Roma parents claim that they trust health workers the most, but they also trust friends, other parents and fam-ily members, followed by official websites of health institutions and the Ministry of Health. Vaccine hesitant Roma parents trust their health providers less than their vaccine support-ive peers. Traditional sources of information (TV, newspapers) are less trusted by both clus-ters of parents. In general, confidence in almost all sources of information is higher among Roma parents than among members of general population.

TV


Radio


Forums, blogs

Social media

Health providers

Figure 6.4.17 – Frequency of various media consumption, comparison between Roma parents hesitantand supportive of vaccination

22%19%

41%

2%2%

1%1%

7%5%

23%

3%2%

14%

6%6%6%

71%75%

56%



In focus groups, Roma parents report collecting information from the media about harm-fulness of MMR vaccines. However, they haven’t changed their decision to vaccinate their child because they thought it was in the best interest of the child, and it was also advised by their paediatrician. However, Roma parents are more likely to state that paediatricians don’t have enough time for them and that they need to ask paediatricians for additional ex-planation several times, but they still don’t have negative attitude towards paediatricians. As for the Internet, parents from Roma population don’t have uniform attitude regarding whether they get informed about these topics through this channel or not.

6.4.11. Media literacyOur results show that media literacy is very low in Roma parents. They almost never look for authors of texts that they read; they do not question the interests of the author to write a certain text. This indicates that respondents do not distinguish between reliable and unre-liable sources, biased and unbiased sources of information, or justified and false argumen-tation. Hesitant parents are even more superficial in their media consumption than vaccine supporters (28% claim they only read the title, 26% they only pick up basic information, in comparison to 8% and 19% of supporters).

Figure 6.4.18 – Confidence in different media, comparison between Roma parents hesitant and supportiveof vaccination

49%50%

46%

34%37%

22%

34%38%

25%

48%48%

46%

48%47%50%

35%32%

45%

90%96%

63%

TV


Radio


Forums, blogs

Social media

Health providers



6.4.12. Preferred channels of communication about vaccinationA total of 84% of Roma parents would like to have more time to talk with their paediatrician, and they would highly appreciate if a doctor would come to their Roma community to vac-cinate children on the location where they live (67% in total). As mentioned before, some of the most important barriers to vaccination in Roma population is lack of knowledge about vaccination and the procedures, so parents express the need for longer contacts with pae-diatricians where procedures and benefits of vaccination would be explained to them in un-derstandable language. Significantly lower percentage of Roma parents mention seminars for parents, websites and forums. The impression is that they do not want, or do not feel ca-pable of communicating in a way which requires a more proactive approach, but prefer to be directly addressed by medical authorities. Hesitant parents report more extensive need for all communication forms, except for talking to paediatrician and parenting seminars.

Figure 6.4.19 – Media literacy, comparison between Roma parents hesitant and supportive of vaccination

4%4%6%

11%12%11%

7%5%

16%

19%19%

26%

11%8%

28%

7%6%8%


I am searching for the authorof the text.

I am searching for different sourcesof the same information on the Internet.

I am thinking if the author of the text has an interest to representa certain viewpoint.

I „pick up” basic information anddisuss them with friends.

I read the title – the text is anywaymere repetition of the title.

I am capable of reading the newsonly in my native language.


Focus groups reveal that all tested channels of communication are positively evaluated by Roma parents. Some of them also pointed out that it would be useful to focus on pregnant women and start education about vaccines during pregnancy.

6.4.13. Confidence in medical authoritiesRoma parents from both clusters have great confidence in official medicine and paedia-tricians in health centres, even if hesitant parents are somewhat less trusting. Alternative medicine such as homeopathy or acupuncture is assessed positively by less than third of Roma parents, whilst traditional medicine is more popular. Roma parents trust the health system in general, pharmaceutical industry and quality control system much more than gen-eral population, with hesitant parents giving lower grades.

Figure 6.4.20 – Preferred channels of communication about vaccination, comparison between Romaparents hesitant and supportive of vaccination

69%66%

86%

71%70%

82%

64%67%

63%

49%49%

57%

25%24%

40%

24%23%

35%

51%54%

77%

84%87%

77%

64%66%67%

Written brochures in health centersthat can be taken home.

Posters in health centers that can beread while waiting.

A telephone line that can be calledfor vaccine-related questions.

TV debates on vaccination withexperts.

Parental forums, blogs.

Websites offering a possibilityto pose online questions to pediatricians, immunologists etc...

Parenting seminars (“Škole roditeljstva”) to address vaccination.

More time allowed to spend talking to my pediatrician.

Roma only: For a doctor to come toour community and vaccinate the children on the spot.



6.4.14. Trust in scienceSuspicion in science and scientific achievements may result in refusing to vaccinate chil-dren. This attitude is easily connected with conspiratorial mentality, or doubts in motives and transparency of not only medical and state institutions. However, Roma parents seem to trust scientific achievements most, and in this aspect the differences between supporters and hesitant are as expected.

Figure 6.4.21 – Preferred channels of communication about vaccination, comparison between Romaparents hesitant and supportive of vaccination

90%94%

76%

16%17%

15%

78%83%

64%

79%86%

47%

71%76%

45%

60%64%

46%

31%33%

21%

71%73%

53%

83%89%

62%

Your pediatrician in healt center

Your pediatrician in the privatesector (if you have one)

Nurses (medical stuff other thandoctors)

Healt system in Serbia

Pharmaceutical industry

National Agency for Quality Controlof Medicines and Vaccines

Alternative medicine (homeopathy,acupuncture, Reiki and similar)

Tradicitional medicine (herbal teas,ointments and similar)

Official medicine



6.5. Analysis of determinants of future vaccination related behaviour - general populationIn further analysis, we tried to explore what determines the intent to vaccinate a child. First, we correlated future vaccination behaviour with all psychological and socio-demograph-ical variables we measured in the research (Tables 6.5.1. and 6.5.2.). The tables clearly show that the intention to vaccinate a child in the future is strongly related to all measured psychological constructs, except for the vaccination knowledge, and that it is weakly relat-ed to all socio-demographical characteristics (the only significant correlation is with type of settlement).

Our next step was to explore how these variables behave as predictors24 whilst reported vaccination intention serves as the criterion in a multiple regression analysis – this allowed us to compare relative contribution of different predictors when used in a given set. Multiple linear regression is a statistical technique that attempts to model the relationship between two or more explanatory variables and a response variable by fitting a linear equation to ob-served data. It is used when we want to predict the value of a variable based on the value of two or more other variables. The variable we want to predict (dependent variable y) is called the criterion variable, whilst the independent variables (x1, x2, etc…) are called predictors. The power of the whole set of predictors in the model is expressed through the percent-age of explained variance of criterion (varies between 0 and 100%), and the relationship between a single predictor and criterion, whilst controlling for other predictors is expressed through so called “beta weights” (vary between 0 and 1).

24 Please note that “predictors” are used in the text as strictly statistical terms – as a set of variables used in the regression analysis to relate to the criterion variable (in this case reported vaccination intention). As we do not have experimental or longitudinal design that would allow us to track their real vaccination behaviour, we cannot imply any causality.

Figure 6.4.22 – Trust in science, comparison between Roma parents hesitant and supportive of vaccination

71%73%

59%

55%59%

39%

17%16%

26%

76%79%

69%

I am amazed by the achievementsof modern science.

I think scientific method is the onlyreliable way of finding the truth about the world.

I doubt in the motives of scientistsnowadays.

I think that science will find the curefor most currently incurable diseasesin the future.



Futu

re b

ehav

iour

re

gard

ing

vacc

inat

ion

Asse

ssm

ent o

f ris

k of

vac

cina

tion

Myt

hs a

bout

vac

cine

s

Supp

ort o

f the

su

rroun

ding

to

vacc

inat

ion

Med

ia l

itera

cy

Con

spiri

ng m

enta

lity

Con

fiden

ce in

the

offic

ial

med

ical

aut

horit

ies

Con

fiden

ce

in s

cien

ce

Know

ledg

e

Con

spira

cy th

eory

ab

out v

acci

natio

n

Future behaviour regarding

vaccination (1)1

0.54**

0.47** -0.36** 0.09** 0.14** -0.32** -0.10** 0.03 0.52**

Assessment of risk of vaccination (2) 1 0.73** -0.37** 0.19** 0.23** -0.43** -0.14** -0.01 0.69**

Myths about vaccines (3) 1 -0.21** 0.17** 0.28** -0.31** -0.09** 0.03 0.70**

Support of the surrounding to vaccination (4)

1 0.01 -0.02 0.52** 0.28** 0.11** -0.27**

Media literacy (5) 1 0.18** -0.10** 0.05 0.30** 0.22**

Conspiring mentality (6) 1 -0.23** 0.03 0.17** 0.29**

Confidence in the official medical authorities (7)

1 0.40** 0.04 -0.46**

Confidence in science (8) 1 0.17** -0.18**

Knowledge (9) 1 0.04

Conspiracy theory about vaccination (10) 1

Table 6.5.1 – Correlation between attitudes, knowledge and behaviour regarding vaccination

* p<.05 ** p<.01 Note: Correlation is a statistical connection between different measures. Correlation coefficient may range from -1 to +1; coefficient sign shows the direction of correlation – if it is positive, it means that growth of one measure is accompanied by growth of the other, if it is negative, growth of one measure is followed by decline of the other. The bigger the correlation coefficient (closer to 1 or -1) the stronger the relation between the measures. Coefficients between 0 and 0.2 are considered low, between 0.2 and 0.5 moderate and bigger than 0.5 -high. The coefficient should be observed together with statistical significance - p. If p<.05, the probability that the relation is accidental is less than 5%..


We will focus on the relation between psychological and sociodemographic variables with future behaviour of parents regarding vaccination.

When observing psychological variables, the strongest barriers for vaccination are estimates of risk of vaccination, belief in myths and conspiracy theories about vaccines. Protecting factors, on the other hand, are the perceived support of the surrounding and confidence in the official medical authorities and science. These findings fit perfectly the psycholog-ical profile of supporters and opponents of vaccination identified in previous studies. The climate of mistrust, unconfirmed information and conspiracy theories reduce parents’ cer-tainty about safety of vaccination, while confidence in the official sources of medical infor-mation and the so-called “descriptive norms” (the perception that the surrounding supports vaccination) make accepting vaccination stronger. Interestingly enough, knowledge about vaccines is not related to future behaviour – being aware of the right information doesn’t in-fluence the intention to accept vaccination, but trust in the unconfirmed information (myths and conspiracy theories) undermines it to a great extent.

Compared with psychological variables, sociodemographic variables are significantly less related to future behaviour: neither the number of children in the household, nor age, edu-cation and socioeconomic status of parents are reliable predictors of future behaviour. One weak, but significant correlation has been detected on urbanity variable – hesitant parents are more likely to live in urban areas.

Futu

re b

ehav

iour

re

gard

ing

vacc

inat

ion

Num

ber o

f chi

ldre

n in

the

hous

ehol

d

Pare

nts’

age

Urb

anity

Pare

nts’

edu

catio

n

Soci

oeco

nom

ic s

tatu

s

Future behaviour regarding

vaccination (1)1 -0.04 -0.01 -0.10** 0.05 0.05

Number of children in the household (2) 1 0.19** 0.03 -0.18** -0.16**

Parents’ age (3) 1 -0.16** 0.18** 0.00

Urbanity (4) 1 -0.26** -0.03

Parents’ education of (5) 1 0.30**

Socioeconomic status (6) 1

Table 6.5.2 – Correlation between vaccination related behaviour vaccination and sociodemographic characteristics

* p<.05 ** p<.01


Figure 6.5.1 – Psychological determinants of future behaviour

Risks of vaccination

Futurevaccinalbehaviour

Media literacy

Knowledge about vaccines

Conspiracy theories aboutvaccines

Myths about vaccinesBeta=.34** (r=0.54**)

Beta=.05 (r=0.47**)

Beta=.06* (r=0.09**)

Beta=.05 (r=0.03)

Beta=.27** (r=0.52**)

In re

gres

sion

analy

sis,

expla

ined

is 35

% o

f var

iance

Figure 6.5.2 – Perceived support of the surrounding and confidence in authorities as determinants offuture behaviour

In re

gres

sion

analy

sis,

expla

ined

is 20

% o

f var

iance

Confidence in officialmedical authorities

Support of the surrounding

Confidence in scienceBeta=.08** (r=0.10**)

Beta=.25** (r=0.32**)

Beta=.28** (r=0.36**)


Figure 6.5.3 – Sociodemographic determinants of future behaviour

Place of residence


Education

Parents’ age

Economic situation

Total number of childrenin the household

Beta=.11** (r=0.10**)

Beta=.002 (r=0.04)

Beta=.02 (r=0.05)

Beta=.02 (r=0.01)

Beta=.05 (r=0.05)

Note: the lines include Pearson coefficients of linear correlation and Standardized Beta coefficients for linear regression and statistical significance **p<.01; *p<.05

In re

gres

sion

analy

sis,

expla

ined

is 1%

of v

arian

ce


The regression model, which compares the power of predicting of these groups of vari-ables, gives similar results: assessment of risk of vaccination, trust in myths and conspira-cies, media literacy and knowledge about vaccines account for 35% of variance in the fu-ture vaccination behaviour; perceived support of the surrounding and confidence in official authorities account for 20%; while all sociodemographic variables account for only 1%.

155Conclusions

Conclusions

7.1. Institutional and legal framework related to vaccination

7.1.1. Legal frame Health workers and some key informants consider the current legal frame to be incomplete (there is no rulebook related to these matters). The most discussed is the mandatory nature of vaccination, its implementation and the proposed penalties for failing to do so. Although the dominant opinion is that vaccination should be compulsory, all agree that the responsi-bilities of medical workers and parents in its implementation need to be defined more pre-cisely. They also suggest that the state should fund a vaccination injury compensation pro-gram for children who experience severe adverse effects of vaccination.

7.1.2 Comparison with EU countriesMajority of respondents agree that our legal frame is largely in compliance with the general EU standards. The differences refer to communication with parents and general awareness.

Some believe that, even if the requirement for compulsory vaccination is not publicly com-municated, it can be regulated the way it was done in some western countries, where chil-dren cannot be integrated in the social system without vaccination. This is believed to be an optimal practice.

7.1.3. Availability of vaccinesMedical workers state that past problems with availability of vaccines were a consequence of (a) insufficient coordination of the work of relevant institutions, (b) inadequate vaccine management in terms of acquisition and storage. The latter was the case with recommend-ed, not mandatory vaccines. However, most respondents agree that the availability signifi-cantly improved in comparison to previous years.

Majority of respondents in this group regret that the production was interrupted in Torlak and suggest that the state should reconsider investing in this industry.

7.1.4. Vaccine transportation and storageAll medical workers agree that there is a rigid mechanism of regulations and measures for storing vaccines in place, and that medical workers are trained to implement it.

7


7.1.5. Immunisation calendarThe immunisation calendar is considered adequate. Some paediatricians suggested a change of the stipulated time for MMR vaccine, due to growing pressure of parents to post-pone it until children start talking. They believe that this would generate a more positive at-titude towards this vaccine.

7.1.6. Legal forms for accepting/rejecting vaccinationKey informants believe that written consent forms for “compulsory vaccines” are unneces-sary as they have no legal value and only generate parents’ suspicions and mistrust in vac-cines. Nevertheless, they believe that consent forms should be used for “recommended vaccines”.

The attitude about refusal forms is ambivalent. These forms are most criticized for not being standardized, while precise wording is necessary for the legal protection of health workers and institutions. Paediatricians state that some doctors offer the form to parents as soon as they show even slight doubts in vaccine, while others try to negotiate with such parents, give them time to think and give them the form to fill out only after several failed attempts of counselling. Roma mediators have no experience with these forms.

7.1.7. Institutions engaged in the process of immunization and their coordination

Perception of institutions

Coordination between institutions and medical workers is being upgraded. Representatives of health institutions don’t think that they are responsible for any decisions about vaccina-tion. They perceive their institutions as implementers of decisions, while they consider high-er, national instances responsible for making them.

Perception of coordination between institutions and their cooperation

Key informants and medical workers believe that all relevant participants in the immuni-sation process are not coordinated well, especially representatives of health insurance, in terms of systemic planning and procurement of vaccines.

There is progress detected regarding cooperation with Roma mediators and communities. Majority of Roma population members had no health insurance or medical records when they started to work with Roma mediators, so immunization was preceded by integration of Roma population in the health system.

7.1.8. The expected trend of immunization coverageAll respondents agree that the coverage of immunization is decreasing – especially in case of MMR vaccine, and they believe that the coverage will keep decreasing, and that only an epidemic may reverse the trend.

157Conclusions

Regarding vulnerable populations, Roma children are most commonly identified as a group under the greatest risk of avoiding vaccination. However, this coverage in this particular group is expected to grow.

7.1.9. Communication of stakeholders

Communication between medical workers and parents

Our respondents from health sector are faced with strong parents’ pressures shaped by media reports about harmfulness of vaccines. They are reluctant to face the hesitant or an-ti-vaccination parents due to several reasons: (a) they don’t feel competent enough to an-swer all parents’ questions, (b) some fear parents’ reaction to persuading, (c) and some aren’t motivated to deal with this, since they believe that the decision about vaccination is individual, and that doctors are not responsible for persuading parents.

Medical workers who are still trying to persuade parents to vaccinate children, use two types of arguments: a. they say that they vaccinate their children too and b. they explain how serious the vaccine-preventable diseases are.


Medical workers state that there is no leading institution responsible for communication and coordination of communication with general public, but they agree that all institutions on all levels should be responsible.

Representatives of informal sectors believe that it is important that this communication is more transparent and more adjusted to ordinary people.

Internet is perceived as the main source of information and simultaneously the main cause for misinformation of citizens. Key informants and medical workers believe that there are fewer and fewer parents who consider paediatricians the main source of information, as well as that citizens’ confidence in the health system is decreasing.

They believe that currently the most widespread myth in public, is the one about the con-nection between MMR vaccines and autism, followed by the one referring to harmful ingre-dients of vaccines, and conspiracy theories related to pharmaceutical companies that pro-duce vaccines only because of their own benefits.

Public opinion is also influenced by growing antivaccination movements. As expected, all respondents have extremely negative opinion of them, especially those originating from the medical circles. They also believe that the media should bear some responsibility for sen-sationalistic images related to anti-vaccination movements. Parents perceived as the most susceptible to ideas promoted by opponents of vaccination are parents of medically vulner-able children (mainly autistic).

Medical workers underline that it is important to ensure greater engagement of vaccination experts who will confront the arguments of the opponents of vaccination, while some key informants believe that this leads to strengthening of these, otherwise marginal forces, and that they should be largely ignored.


Key informants and medical workers believe that representatives of the health system shouldn’t only react to antivaccination attitudes and publicly confront the representatives of the antivaccination movement, but continuously strengthen pro-vaccination climate in public.

Strong and weak links in communication related to vaccination

Health sector representatives believe that the strongest link, currently, are paediatricians, who are making efforts to raise general awareness of parents, especially Roma, about the importance of vaccination. Negative influen0ce originates from the media, electronic in par-ticular, from generally lower confidence in the health system, caused by past events relat-ed to faulty vaccines, strengthening of anti-vaccination movement, as well as general igno-rance about vaccination.

7.1.10. Immunization-related trainings of health professionalsThe number of training courses for medical workers is growing, especially after compulso-ry accreditation has been introduced. Paediatricians say that they have attended courses about immunization, as well as workshops, round tables and lectures given by foreign ex-perts. Sometimes, however, these trainings serve as forums for spreading antivaccination ideas, and typically they do not offer guidelines for communication with parents. Roma me-diators also stress the significance of courses and lectures they attended, and say that this has helped them a lot during fieldwork.

7.2. Knowledge, attitudes and practices of parents regarding the immunization of children -Integration of qualitative and quantitative findings-

7.2.1. Cluster population presence based on vaccination attitudesMajority of parents claim that they had their children vaccinated according to the immuni-sation calendar (92.3%); 4.3% hesitated, but took them to be vaccinated, and 3% refused some vaccines. Less than 1% of parents refused vaccination completely. As for future be-haviour of parents regarding vaccination of children, the situation is not very encouraging: although majority of parents still have no dilemma and claim that they will surely adhere to the calendar (79%), quite many of them state that they will delay some types of vaccination, but will probably do it (13.8%) and 4.4% will skip some vaccines; the number of absolute opponents of vaccination is still small (1%).

When these two parameters are compared, it is obvious that the situation is more unfavour-able regarding the future vaccination intentions than regarding the parents’ past behaviour. Although the number of parents who absolutely refuse vaccination is not rising, the num-ber of hesitant parents is (those who would postpone vaccination, or skip some vaccines).

If fears of this group of parents are not adequately addressed, they may become “radical-ized”, so it would be good to aim future interventions at this target group. The following anal-ysis presents their sociodemographic and psychological profile.

159Conclusions

7.2.2. Sociodemographic profiling of clustersThere is no difference between supporters and hesitant parents on most of the measured sociodemographic characteristics. The only significant difference refers to the place of resi-dence - hesitant parents are more likely to live in urban areas and they are somewhat more likely to be well educated.

7.2.3. Vaccine-related experiences with the public health system Most parents stated that they were informed about the next vaccination (86%), about dis-eases which are prevented with the administered vaccine (76%), about side effects (79%) and how to deal with them if they appear (82%). 42% of parents from the general popula-tion stated that their child had mild reaction to a vaccine, and only 3% stated that child had a strong reaction. Some parents (17%) weren’t answered their questions about vaccination and their percentage is higher among residents of Belgrade (25%). Vaccine shortage was reported by 14% of parents.

No significant differences in vaccination experience emerged when respondents’ answers were broken down by age, education, region, employment and financial situation. About 17% were invited by phone or got written notification from the health facility and it seems that this practice is more common in rural areas (22%). In rural areas, parents experienced less waiting for vaccination in the health centre (16%), indicating that health centres in ur-ban areas are more crowded (25%). Parents from Belgrade were more likely to state that they were left with unanswered questions after visiting a doctor (25%).

Hesitant parents are more likely than supporters to mention their negative experiences when communicating with paediatricians (they didn’t answer questions, they didn’t provide information about adverse effects or how to deal with them), they are also more likely to state that vaccines weren’t available or that they had to wait long, as well as that adverse effects occurred.

It is encouraging, though, that in spite of all the registered differences, the results don’t sug-gest that total experience was negative in either of the two groups. When they were asked to give general assessment, they mainly described their experience as positive (96% of supporters and even 84% of hesitant parents).

Qualitative data reinforce these conclusions. Supporters of vaccination had no experience with reactions to vaccines, except for mild reactions such as fever or mild redness, and they were familiar with these potential effects because paediatrician informed them about this. However, some parents state that vaccination is certainly traumatic and stressful for chil-dren. None of the interviewed parents mentioned serious complications after receiving vac-cines, although, quite expectedly, opponents of vaccination reacted more negatively to all effects.

In line with their initial attitude towards vaccination, parents have different opinions regard-ing vaccinating children with compulsory vaccines. They say that MMR vaccine is unneces-sary and they are suspicious about BCG vaccine which is given to children right after birth, without asking the parents. For some parents who oppose vaccination, the origin of vac-cines is a major problem, since they don’t trust imported vaccines much.


As for postponing vaccination, parents with positive attitude towards vaccination and Roma parents specify sickness as the most common reason for this. Opponents of vaccination ad-vocate postponing of MMR vaccination and mention autism.

Almost none of the parents with positive attitude towards vaccination, as well as Roma par-ents, have experience with signing forms. Only a few parents with negative attitude towards vaccination have signed this form, and their attitude towards this is negative.

7.2.4. Vaccination-related knowledgeKnowledge about the principles of vaccination is generally very poor in all tested groups: more than 10% of parents did not answer correctly a single question, while only 1.4% re-sponded correctly to all questions. More than half of parents (52.4%) answered two or fewer questions right. Parents mainly knew what revaccination was and which diseases BCG vac-cine prevented; one out of five parents knew what MMR was (this vaccine is “stigmatized” by the media for its alleged connection with autism), and one in seven knew why DiTePer was used.

Between the groups of parents who support and don’t support vaccination, no difference in knowledge was detected. Older and better educated parents scored better on the test, while Roma parents knew a lot less than parents from general population.

There is weak correlation between personal assessment of knowledge and objective knowl-edge about the immunization process.

In focus groups, parents with positive attitude towards vaccination consider themselves av-eragely informed and they believe that parents in Serbia are generally uninformed. Parents from Roma population perceive themselves as even less informed about these topics, while parents with extremely negative attitude consider themselves better informed than the rest of the population.

Parents usually mention tuberculosis, measles, hepatitis B, mumps as diseases that vac-cination protects children from. They are not very familiar with the consequences of these diseases. Opponents of vaccination usually consider measles harmless, and vaccines as no guarantee of any protection.

Supporters of vaccination and Roma parents have some information about the outbursts of vaccine preventable diseases, while opponents of vaccination deny this possibility and doubt that vaccination can help – they both mention recent epidemic of measles in Romania. While opponents consider this a failure of immunisation, supporters believe that it was a consequence of reduced coverage.

Parents who have vaccinated their children, both those with positive attitude towards vacci-nation and those with negative attitude, claim that they are aware of the importance of ad-hering to the immunization calendar. Roma parents don’t clearly understand the reasons for this, and why there is a need for revaccination. Parents with negative attitude towards vaccination believe that the number of vaccines, revaccination and schedule are forced by the interests of the healthcare system and pharmaceutical companies. All parents agree that combined vaccines - giving several different vaccines in one take - are not good for the child – it is not possible to track the effects of vaccines, and such administration provokes „chemical shock“ in child’s body.

161Conclusions

7.2.5. Assessment of the risk of (non)vaccinationParents from general population are most likely to state that, all in all, vaccination is useful (84%), and that vaccination should be mandatory (72%), although 40% state that parents who refuse to vaccinate children should bear the consequences, 77% are worried that their child will get a disease if not vaccinated. So, parents are more likely to recognise benefits than bar-riers of vaccination. However almost half of general population members (49%) agree (com-pletely or somewhat) that they are worried about the side effects of vaccines, 44% are worried that vaccines could trigger other diseases, 34% state that they are worried about multiple vac-cines in one take. 47% of parents were worried about the quality of vaccines.

When assessment of vaccine-related risks was analysed by socio-demographic data, again the same pattern emerged: only education and region were somewhat significant in gener-al population. Less educated parents reported to be less worried about side effects of vac-cines (34%), other diseases that can be triggered by vaccination (28%), risks about multiple vaccines in one shot (21%) or too early age for vaccinating (14%). Belgrade parents re-ported being more worried about all those issues, in comparison to parents from Vojvodina, who seem to be less worried. 60% of parents from Belgrade were worried about the side effects of vaccines comparing to 38% in Vojvodina. 53% of parents from Belgrade reported that they were worried that vaccine could trigger other diseases comparing to 34% of par-ents from Vojvodina.

The attitudes towards vaccination are generally good among supporters and hesitant par-ents. Parents from both groups believe that vaccination is useful; supporters are somewhat more likely to share this opinion, as expected. While supporters of vaccination worry about vaccine-preventable diseases, but not about the safety of vaccines, hesitant parents worry about both. This is an important difference between this group of parents and the opponents of vaccination, who usually consider vaccine-preventable diseases “mild” or “diseases that strengthen the immune system”. Hesitant parents, however, detect risks on both sides and they seem to find it hard to “rank risks”, or to estimate what more dangerous for a child is.

In the qualitative part of the research, parents with positive attitude towards vaccination spontaneously mentioned numerous advantages of vaccination: prevention of epidemics, precaution, psychological stability, protection of the child and the whole society. Roma par-ents were less specific about the advantages of vaccination, but they were generally aware of their role in disease prevention. Parents with positive attitude towards vaccination detect negative propaganda against vaccination, and complain that health professionals do not confront it enough. Another disadvantage is absence of guaranteed protection from diseas-es after vaccination. The third disadvantage is absence of uniform attitude of medical work-ers towards vaccination.

Parents with negative attitude towards vaccination believe that major advantages of vacci-nation are collective immunity and capability to eradicate diseases.

Parents with extremely negative attitude see no benefits in vaccination. The perceived dis-advantages primarily refer to the existing legal frame that stipulates compulsory vaccina-tion, fines for not doing so, no information about vaccines, about the composition of vac-cines, the fact that vaccines are imported, and proof that vaccines are simply not beneficial. Parents with negative attitude towards vaccination say that they would advise other parents either not to vaccinate their children or to get informed about harmfulness of vaccination first, and then make the decision.


7.2.6. Myths and conspiracy theories about vaccinesMyths related to vaccination are not widely accepted among general population members. However, it is worth noting that almost one third of parents believe that imported vaccines are of poor quality (32%) and that their quality is not properly controlled (33%). Similar share of parents believe that too many vaccines hamper children’s immunity (26%), that it would be better if children were older when vaccinated (27%) and that medicine today can cure diseases prevented by vaccines more successfully than side effects of immunization (30%). Only small percentage of parents agree that MMR causes autism (15%), that vaccine con-servatives are toxic (16%), that measles are actually harmless (15%), that it is better for a child to overcome a disease and strengthen its immunity rather than to be vaccinated (16%) or that vaccine preventable diseases are mild diseases (11%).

Although we did not register far-reaching differences in endorsing vaccine-related myths, once again they were less endorsed by less educated parents and more endorsed by res-idents of Belgrade, and unemployed parents. The group of hesitant parents who will give only some vaccines to their children agreed with a number of myths, among which that MMR causes autism (57%) and that vaccines preservers are toxic (57.6%), and even “All measles are harmless” (42%), and “Medicine can more easily cure vaccine preventable dis-eases than it can cure adverse vaccination reactions” (49%).

Myths about vaccination are not widely accepted by supporters or by hesitant parents, but hesitant parents seem to believe them more. The most widely accepted are the myths about control of quality and the process (dynamics) of administering vaccines. The least accepted myths are those that minimize the danger of vaccine-preventable diseases.

Hesitant parents are more likely to believe in conspiracy theories than supporters of vac-cination and these differences are systemically registered on all points of the story that the authorities and pharmaceutical industry hide data about the dangers of vaccination. Results, however, don’t suggest that hesitant parents accept such statements without re-serve, but that they are indecisive, while supporters of vaccination reject them strongly.

7.2.7. Vaccine related decision making; support for vaccination in social environmentMajority of parents (90%) see health providers as greatest supporters of immunization, but also state that their family (80%) and close friends (70%) support it. However, other parents are perceived as supporting vaccination less (58%). Less than half of parents and only one third of Central Serbia residents recognized media as an instance supporting immunization (46%), probably because of the sensationalistic anti-vaccination elements that the public has been exposed to over the past years.

Supporters of vaccination assess that all stakeholders in their surrounding support vaccina-tion (especially family and close friends), while hesitant parents are more likely to perceive their surrounding as hesitant.

Hesitant parents are more likely to consider the decision about vaccination an individual act and they don’t think much about the dangers of such decision for public health. They are less likely than supporters to think that parents who don’t vaccinate their children should be punished and that vaccination should be compulsory.

163Conclusions

In qualitative research, numerous parents, even those with positive attitude towards vacci-nation, report that they have strong doubts about vaccination. They make decisions togeth-er with their spouses. Many parents have consulted their paediatrician - some paediatri-cians support vaccination openly, while others take neutral stand, saying that parents have the right to decide whether they will vaccinate their children or not. In general, the decision about vaccination is perceived to be individual and consequences for wider public are not recognized.

When parents (especially anti-vaccination parents) are faced with anecdotic examples of positive and negative experiences with vaccination, some regularities are detected in their reasoning: a. they tend to interpret correlations causally, or to perceive events as causing one another (vaccine as a distinctive event is very adequate for this type of interpretation), b. there is no time limit between events related in this way (all unwanted effects that hap-pen months after vaccination are attributed to vaccination) and c. they fail to perceive dif-ferences between mild and serious adverse effects – they perceive both as serious risk of vaccination.

7.2.8. Trust in medical authoritiesThe picture of public opinion when it comes to confidence in health authorities is rather en-couraging: 82% of parents trust their paediatricians (89% of supporters, and 61% of hesi-tant) and official medicine (79%). Supporters are more likely (84%) to trust official medicine than hesitant (62%). Confidence in institutions connected with production (43%) and qual-ity control of drugs (47%) is somewhat lower, particularly among hesitant parents (36% of hesitant parents have confidence in the national agency for quality control, and only 27% in pharmaceutical industry).

7.2.9. Trust in scienceBoth groups of parents have extensive confidence in science, although there are some ex-pected, minor differences between hesitant parents and supporters of vaccination. The first group is more likely to suspect the motives of scientists and scientific method as the only reliable way to find out the truth about the world.

7.2.10. Media consumptionThere are no striking demographic differences when it comes to media consumption re-garding health-related issues. Better educated parents from general population use official Internet sites and forums/blogs more. Majority of parents (67%) receive information about vaccination from health providers. About 22% use TV, Internet sites (26%) or social media (19%) to inform themselves about vaccination. About 12% use printed media and forums and blogs (18%) while only 3% use the radio. Parents with low education level use all me-dia to a lower extent, while parents with high education use the Internet and forums/blogs to a significantly larger percentage.

Both groups of parents mainly get informed about vaccination by medical workers, and in their immediate surrounding (family members and other parents). Parents who are hes-itant regarding vaccination are more likely to use all types of media than supporters of


vaccination, but this difference is particularly visible in case of internet – they use both offi-cial and informal websites (forums, blogs and social networks).

Supporters of vaccination seem to consult medical workers more. This may mean that hes-itant parents are more proactive and independent in seeking information, while supporters of vaccination predominantly rely on official authorities. Quite expectedly, hesitant parents trust most of the available sources less than supporters of vaccination do. This is most strik-ing in case of traditional media.

Qualitative data corroborate these findings: Roma parents are more likely to state that pae-diatricians don’t have enough time for them and that they have to ask for explanation sev-eral times sometimes because they don’t understand something, but they generally have no negative attitude towards paediatricians. Parents with positive attitude towards vacci-nation and Roma parents trust paediatricians most, while parents with negative attitude to-wards vaccination trust the internet more. These parents say that they don’t trust anyone or that they trust people who have experiences with vaccination, or those with negative experiences.

7.2.11. Media literacyInternet consumers in Serbia are not very likely to critically challenge information they find on the internet, look for authors, different sources of news or read news in foreign languag-es. Hesitant parents are somewhat more likely to behave like this, but the differences are mainly minor.

7.2.12. Preferred channels of communicationParents claim that they need more information about vaccination, through all available channels. Supporters of vaccination seem to prefer written material available in health insti-tutions (brochures, posters), while hesitant parents prefer interactive materials (parent fo-rums, websites where they can ask questions). Both groups would like to have more time to speak to their paediatrician.

In focus group interviews, all parents state that they would like to have more information about the quality of vaccines and their ingredients and a clear list of adverse effects, with particular focus on MMR and its connection with autism.

Finally, parents prefer different sources of information: promotional materials, brochures, programs, but also organized lectures in health centres. Parents from Roma population believe that it would be very useful to pay attention to pregnant women and educate them about vaccines.

7.2.13. Determinants of future vaccination-related behaviour Correlation and regression analysis suggest greater importance of psychological mea-sures than of sociodemographic characteristics in predicting future vaccination behaviour. Compared with psychological variables, sociodemographic variables are significantly less related to future behaviour: neither the number of children in the household, nor age, edu-cation and socioeconomic status of parents are reliable predictors of future behaviour. One

165Conclusions

weak, but significant correlation has been detected on urbanity – hesitant parents are more likely to live in urban areas. Assessment of risk of vaccination, believing in myths, theories of conspiracy, media literacy and knowledge about vaccines can mainly predict future vac-cination behaviour of parents; perceived support of the surroundings and confidence in offi-cial authorities somewhat less; while no sociodemographic variables can offer much in this aspect.

The strongest barriers for vaccination are assessment of the risk of vaccination and trust in myths and conspiracy theories about vaccines. Protective factors are mainly confidence in the official medical authorities and science, as well as perceived support of immediate and wider surroundings. Knowledge about vaccines is not related to future behaviour – being aware of accurate information doesn’t positively relate to the intention to vaccinate, but be-lieving in inaccurate (myths and conspiracy theories) undermines it to a great extent.

7.2.14. Roma parents’ specific experiences with the health systemRoma parents report positive experiences with vaccination, similar to those of general pop-ulation. They are somewhat less likely to take their children for vaccination to health cen-tres, and more likely to be reminded by relevant institutions. Despite highly positive expe-riences, only 72% of Roma parents took a child to vaccination on their own following the immunization calendar (compared with 88% in the general population). It is obvious that the health system is making efforts to increase immunization coverage of Roma as almost one third of Roma received written notification to bring their children to immunization (25% of parents from urban areas and 47% from rural areas were invited through a written notifi-cation). One third of Roma parents from rural areas were invited through a phone call from a health facility.

More than 90% of Roma children have a health insurance card, but one out of five parents claim that it was difficult to obtain the card. There are not many testimonials about drastic experiences of discrimination in medical institutions. However, one third of Roma parents are under the impression that they wait longer in health centres than members of other pop-ulation do, and that they are treated impolitely.

As the main barriers for vaccination, Roma parents specify insufficient information and in-adequate personal organisation. Roma don’t complain about the distance from health cen-tres or their impossibility to travel there. Health mediators are active in some communities. However, in the communities where they are visible, their activities are evaluated extremely positively. They visit families in Roma communities regularly, they remind them of the immu-nisation calendar and offer assistance with vaccination.

Roma parents see less risks and more benefits of vaccination than majority population. They claim that they accept official medical recommendations as necessary and don’t ques-tion them much. They have strong confidence in medical workers and scientific achieve-ments. Myths and conspiracy theories are less widespread among Roma parents. It just needs to be examined whether this is a result of poorer knowledge or of stronger confi-dence in the health system. Roma are more likely than members of general population to detect the support of the surrounding for vaccination. They are more likely to believe that their surrounding supports vaccination. Roma parents are more likely to be afraid of fines if they don’t vaccinate their children, and less likely to believe in conspiracy theories. They are more likely than members of general population to perceive non-vaccination as


irresponsible behaviour. In qualitative research, however, some parents from Roma popu-lation stated that they were afraid when their children received vaccines – because of the growing rumours about harmfulness of vaccines.

Roma parents are less likely to read newspapers, and a lot less likely to use the internet, but they trust all sources of information more than general population members do. Their knowledge about vaccination is significantly poorer in all aspects. Almost half of them can’t answer any of the seven questions, and 90% of Roma parents can’t answer two or fewer questions. They are also less advanced media users – they neither question the sources of information nor seek additional information. As for collecting information about vaccination, Roma parents would like to talk to their doctor more, and they would also support vacci-nation that takes place in the field, in Roma communities. Given that they don’t use the in-ternet to collect information much, they don’t want to receive information about vaccination through forums or blogs. They seem to prefer direct communication with authorities.

167Recommended measures for enhancing vaccination coverage in Serbia

vaccination coverage in Serbia

8.1. Recommendations for communicating with parents (guidelines for tailoring vaccine-related interventions)As for communication between the scientific community/decision-makers and the public, it is important that it has a form of a dialogue, not a monologue, or that the scientific commu-nity responds to questions and problems marked as important by the public. Rigid approach that includes teaching the public, sometimes even condemnation or criticism for misbeliefs or unfounded fears, has proven to be inefficient or not efficient enough (Goldenberg, 2016). Such insensitivity can be counterproductive and can alienate hesitant people or those with freshly formed attitude. This doesn’t imply, of course, that public misbeliefs shouldn’t be cor-rected and that the public shouldn’t be scientifically “educated”, but that there is a need to understand attitudes or hesitation of the other side, appreciate them and address them in communication.

Furthermore, it is very important to communicate absolutely accurate information and nev-er make unfounded generalization. For instance, the statement “vaccines are 100% safe” can’t be supported by empirical evidence and it is irresponsible to give such and similar statements trying to assure the public of the need for vaccination.

In this document we follow these general principles:

The decisions about vaccines made by the public are complex and not guided by scien-tific evidences only, but by mixed scientific, psychological, sociocultural and political reasons that need to be addressed.

It is necessary that medical workers and experts for communication with the public (psy-chologists, sociologists, politicologists) take part in the process of directing the public to immunisation.

Although it is very important that officials communicate positive, evidence-supported information about the safety of specific vaccines and about the ratio of risks and gain, it is not sufficient to rely on education of the public only.

When communicating with the public, medical workers, epidemiologists, makers of pu-blic policies and politicians should adhere to the following: appreciation of patients (in this case parents and children), transparency, accuracy regarding potential risks and benefits.

8 Recommended measures for enhancing


Confidence of the public in vaccines is changeable and depends on context. In order to maintain or regain confidence, it is necessary to understand what potential users are afraid of, what their micro and macro environment is like, their ideology and socioeco-nomic status.

There is a need to systematically monitor the mood of the public, as well as specific concerns and arguments against vaccines that appear and change over time (such as for instance the «global vaccine confidence index», ECDC, 2017).

8.1.1. The reasons for specific behaviour of parents towards vaccination (WHY)In an attempt to discover the reasons for anti-vaccination mood of the public, experts have identified three large spheres of potential reasons: in the individual sphere - parents’ fear/concern for children; in contextual sphere - distrust in the system institutions; in the so called «transcendental» sphere-ideological or religious beliefs (Picture 8.1.1.).

In our research, ideology was not identified as a strong barrier for vaccination – in quanti-tative survey, parents disagreed with the statement that their religious beliefs prevent them from vaccinating their children; this was not spontaneously mentioned by parents in the fo-cus groups either (even in the anti-vaccination group). However, we have evidence of par-ents’ concerns and the lack of trust in the health system in some groups of parents.

Relying on quantitative data for supporters and hesitant parents, and qualitative data for anti-vaccination parents, we have segmented several types of concerns (from consequenc-es of vaccination, but also non-vaccination), as well as several institutional stakeholders (paediatricians who are directly communicated with, the health system, the science and the pharmaceutical industry). Parents assessed how concerned they are about vaccine pre-ventable illnesses, as well as about adverse reactions to vaccination; they also assessed their trust in different stakeholders. This enabled us to profile different clusters of parents – opponents of vaccination, hesitant parents and supporters of vaccination (Picture 8.1.2.) by these variables

Picture 8.1.1 – Model of antivaccination sentiment and salience

Trans

cend

ental

sphere Contextual sphere

Individual sphere

Concern

3

3 3

22

2

1DistrustIdeals

Source: UNICEF, 2013, page 26


While supporters of vaccination are primarily concerned about the possibility that their chil-dren may get some vaccine-preventable disease, and opponents of vaccination are con-cerned about the adverse effects of vaccines, hesitant parents worry about both. This group of parents trust paediatricians and medicine fully, they have somewhat less confidence in the health system, and even less in the pharmaceutical industry (of all institutions, pharma-ceutical industry has the most negative image in public).

8.1.2. Recommendations about communication contents (WHAT)The aim of the recommendation is to empower parents who doubt, worry and hesitate to vaccinate their children to do this, without sensitizing majority of population who vaccinate their children to antivaccination contents. We do not insist on communication with extreme opponents of vaccination, since research results suggest that, when faced with arguments in favour of vaccination, their opinion is either radicalised or stays the same, as we highlight-ed in the literature review section. This is best illustrated in Picture 8.1.3.

Picture 8.1.2 – Clusters of parents by presence of specific barriers towards vaccination

High Medium Low

Worry aboutdiseases(VPD*)

Worry aboutthe effectsof vaccines

Mistrust inpediatricians

Mistrust inthe health

system

Mistrustin science

Mistrust inpharmaceutical

industry

*VPD – vaccine-preventable diseas


Hesitantparents

Supporters ofvaccination


It is important to adopt different communication strategies for broad public and with hesitant parents, i.e. to tailor messages for different segments of public differently (WHO, 2013) – when communicating with the public, insist on dangers of vaccine-preventable diseases, as well as on extensive immunization coverage in EU countries and support that vaccination has in Serbia (according to the results of this study), while specific concerns of hesitant par-ents should be addressed in direct communication between doctors and parents (Horne et al., 2015). Our quantitative data revealed that hesitant parents wish to communicate more directly with their health care providers, that they were more often in the situation when they did not have their vaccination-related questions answered. Vaccination should be pre-sented as taking care of children, as the best way to protect one’s own child as well as oth-er children, as a tool at parents’ disposal, which wasn’t available to parents in the past (it is highly efficient to tell anecdotes or show photos of parents queuing for vaccines against children’s paralysis or pertussis). This is especially important if we have in mind the lack of basic knowledge on vaccine preventable diseases, as established in the knowledge test in the survey.

Concrete recommendations for communication with the public (Table 8.1.1) rely on two types of appeals: emotional and rational. Rational appeal includes informing the parents – using adequate wording, fair, transparent, but within the limits they are interested in. Moreover, it includes assistance with decision-making, primarily regarding risk assessment – instead of being assessed with the categories «all or nothing», risk is a matter of degree (a good analogy - «It is dangerous to live in a building made of asbestos, but not to walk by it»). This type of “all or nothing” reasoning was evident in the focus group discussions. Therefore, the risk of adverse effects of vaccines does exist and it should not be claimed that vaccines are 100% safe, but it is small (what may help are analogies with other, riski-er health behaviour, such as using analgesics or antibiotics, or everyday risks that we are exposed to, such as driving a car). Keeping parents informed about extensive vaccina-tion coverage and public support to vaccination, facilitating formation of the so-called de-scriptive norms (the idea of what majority of people are doing), which tend to be more effi-cient in changing behaviour than the so called prescriptive (what should be done) (Cialdini, 2007). Emotional appeal includes two components: one is illustration of the consequences

Picture 8.1.3 – Probability of changing the opinion about vaccination

Adapted from WHO, 2016, page 10

Hesitant


Passionateopponents ofvaccination

Moderate/high

Low

Very low/zero


Communication between paediatricians and parents is even more important, consider-ing the introduction of electronic health insurance card which disables direct insight in the information in the e-card or in the electronic medical records. As for technical issues as-sociated with vaccination, if parents are interested in the system of quality control of vac-cines, the approach should be transparent and it should be explained that it is not different from that applied in other European countries. It should also be explained that vaccines are stored in the so called «cold chain» and that only sterile syringes for single use are dis-bursed. These specific worries were raised in the focus group discussions and should be addressed in discussion with parents.

Moreover, communication with parents should be based on psychological principles of mak-ing decisions about vaccination (Table 8.1.2).

Table 8.1.1 – Recommended contents for communication with parents

Public Paediatrician-parent

Inform the public about vaccine-preventable diseases and their consequences Show empathy, do not condemn parents

Insist on the importance of vaccination ON TIMEPresent vaccination as an important

measure for protection of children’s health, empower parents, proactive approach

Appeal using anecdotic illustrations of the consequences of diseases

to protect children’s health

Assist the assessment of vaccination and non-vaccination risks

Inform the public about extensive vaccination coverage in the EU

Respond to typical argumentation and questions of opponents of vaccination

Inform the public about positive parents’ attitudes towards vaccination in Serbia (UNICEF study)

Talk about personal decisions as an example (doctor who vaccinates his

children and grandchildren)

Note: emotional appeal, rational appeal

of vaccine-preventable diseases (studies suggest that appeals that include data about ep-idemics accompanied by anecdotes are most efficient), and the other is empathising with parents and empowering parents to make the decision (Table 8.1.1).


Paediatricians should encourage parents to ask questions, empathise with their concern («I understand that you want the best for your child»), be allies («I want the same thing»), pro-vide accurate information about the coverage of vaccination, as well as about the risks («It is not 100% safe, but we are exposed to much greater risks every day – we take aspirin, antibiotics, we ride in a car…»).

Brochures available to paediatricians may answer two groups of questions: questions asked by all parents, and specific questions asked by hesitant parents (box 2). These questions are mapped following the quantitative data on knowledge, myths about vaccination as well as qualitative data exploring the chain of concerns even further.

Table 8.1.2 – Psychological principles of decision-making and their implementation in communication

Psychological principle Implementation in communication between doctors and patients

Naive realism: People assume that their perception of the world is right.

Try to understand what your users are telling you. Are they insecure and seeking support? Different methods of communication should be used with people who question the safety of vaccination or have decided not to vaccinate their child.

Belonging to a group: The perception of belonging to a group meets a number of psychological

needs – from the perception of the world that they share to mutual support and sense of meaning.

If patients are identified with antivaccination group, they should be told that the reasons for rejecting vaccination are different, as well as that the “continuum of indecisiveness” is long

and that they are not a homogenous group, and offer them alternative groups for identification.

Descriptive vs prescriptive norms: For change of behaviour, it is more efficient to know what other people are really doing than what should be done.

Communicate accurate data about the percentage of people who decide to vaccinate their children

Reactance: When faced with arguments that oppose major beliefs, instead of questioning

their belief, people just strengthen them more.

When communicating with parents, their beliefs shouldn’t be directly and roughly

attacked, to avoid “radicalization”.

Overweighing of negative information: When making conclusions or decisions about behaviour, people tend to consider negative

information more important than positive.

Show understanding for parents’ fear of consequences of vaccination, but also

inform parents about the consequences of rejecting vaccination and about symptoms of

diseases children are vaccinated against.

Attributions: People make assumptions about other people’s motives. These

assumptions are usually made on the basis of the general picture they have of people.

It is important to build and maintain the relationship of trust with parents, so that they don’t suspect your motives. Patients should be told, sincerely,

what you would do if you were in their shoes.

Common goals: If two people or two groups of people have a common goal, they can overcome

their conflicts; introduction of superior goal is used as a technique for resolving conflicts.

Inform parents that you are on the same side and that you are, same as they are, primarily interested in children’ welfare.


Typical contents of a brochure

Questions asked by all parents

How does vaccination work?

Which diseases are children vaccinated against?

Why is it important to vaccinate a child?

Why is it important to observe the immunization calendar?

When shouldn’t a child receive a vaccine?

When should I worry in case of adverse effects to a vaccine?

Questions asked by hesitant parents

What do vaccines contain?

How is vaccine safety examined?

How are vaccines stored?

Are diseases preventable by vaccines really serious?

Why is a child vaccinated against so many diseases?

Can vaccines overload child’s immune system?

Is it more dangerous to vaccinate or not vaccinate a child?

Do the scientific community and medical workers agree about vaccination?

As for the training of medical workers, it is necessary to improve its quality and prevent its transformation to forums for spreading myths and doubts. In-depth interviews with key in-formants revealed that, although the trainings about vaccination are offered to health work-ers, they do not address their communication skills, and sometimes even serve as a plat-form for anti-vaccination arguments. Key informants also stated that the vaccination issue is not present enough in educational curricula. It is therefore necessary to engage medi-cal schools and faculties, as well as communication experts. Questions about vaccination may be included in the tests for pupils, students and post-graduates. These interviews also revealed that the vaccination decision is typically viewed as an individual decision of par-ents, and that health workers aren’t responsible in helping them to reach an optimal deci-sion. Hence, emphasis should be placed on the fact that communication with parents about vaccination is doctors’ responsibility, that this is not a private and personal decision of each individual, but a decision about public health. Doctors should be empowered in this pro-cess, they should be trained to communicate successfully, supplied with adequate materi-als and informed about relevant digital contents. They should be provided with brochures that will facilitate communication and equip parents with written material that answers most of their questions. There is also the need for opening a line of communication between doc-tors and higher healthcare institutions that they can address should they have any doubts (Henrikson et al., 2015; Danchin & Nolan, 2014). This is corroborated by quantitative sur-vey in which hesitant parents preferred interactive tools for vaccine-related communication.


8.1.3. Recommendations about communication channels (HOW)Instead of extensive investing in TV promotion, which involves difficult targeting of specif-ic segments of the audience and usually gain disproportionate to the investment, commu-nication with the public should be conducted through billboards displayed in public places and particular attention and effort should be paid to creating visible pro-vaccination internet contents. The official health institutions engaged in the process of immunization need to in-clude information about vaccination in their webpages, with frequently asked questions and answers to typical parents’ fears and arguments of the anti-vaccination movement. Parents should be reached through posters displayed in health centres, schools, through brochures and paediatricians. In line with the trends of automation, parents can be send an SMS or email instead of called – investments in these systems pay off quickly, and they were suc-cessfully introduced in many developing countries (Tozzi et al., 2016). On the other hand, given that new digitalized medical ID doesn’t enable parents to be reminded of the vaccines and when a child received them, it would be good to introduce personal paper records. Talking about vaccines can be also included in the program of parenting schools, so that fu-ture parents can be informed about the calendar of immunization on time and have their po-tential worries addressed. Workshops for paediatricians should be more frequent and par-ticularly address the skills of communication with parents.

Table 8.1.3 – Recommended channels of communication with different audiences

Public Paediatrician-parent Decision-makers-parent

Billboards displayed in public places Posters in health centres Workshops

Make pro-vaccination Internet contents visible during browsing

Brochures in health centres – assisting communication with hesitant parents and opponents of vaccination

Identify potential «figures of the pro-vaccination movement»

for promotion of the benefits of vaccination

(celebrities, experts, pro-vaccination bloggers…) and

make them more visible

Parenting schools: talk about vaccination

Introduce personal paper vaccination records

Automated notification of vaccination (SMS or e-mail)

Update websites of health centres, introduce the section

with frequently asked questions and «online» paediatrician to

answer questions occasionally


8.2. Institutional recommendationsReinforce the system of procurement of vaccines – interruptions of supply and procure-ment through the private sector had a negative effect on the confidence in the system and opened a public discussion about the quality of available vaccines, which was misused by the anti-vaccination lobby for its promotion. Every future interruption of supply threatens to annul the effects and investments in communication/public marketing of vaccines and vac-cination. Each such situation requires additional and intensive communicational response («crisis communications») in order to retain confidence and react adequately to the ques-tions that arise.

Continue working with Roma mediators. Given that the research results suggest a whole range of positive effects of mediators’ work (regarding immunisation coverage, but also in-tegration of Roma in the health system), we suggest expanding of network and providing support to the current, and permanent availability of information about vaccines in the lan-guage and in the way most acceptable to Roma population.

Empower the leadership of Batut through more inclusive and more transparent process of working on doctrinaire, legal and professional acts. This process should also include the media, associations, the civil sector, but also health insurance and insurance compa-nies and other stakeholders with an important role in promotion of vaccination in developed countries (vaccines are relatively cheap, they reduce the risk of diseases, and thus insur-ance costs).

Evaluate implementation of the decision about compulsory vaccination. The focus should be on the format of invitation to vaccination; measures following rejected vaccination aimed at explaining parents why vaccination is necessary; penal measures; refund/com-pensation in case of severe adverse effects; using forms (no standardization) for rejecting vaccination, as well as abandoning the practice (where it still exists) of using forms for ac-cepting vaccination.


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179Appendices

Appendices

Appendix 1 Results of internet search about safety of vaccines: illustration of the ratio of pro and antivaccination contents

Appendix 2 The list of internet contents about the fight against vaccination

Appendix 3 Guide of interview with key informants

Appendix 4 Guide for discussion in focus groups (general and Roma population)

Appendix 5 Questionnaire for quantitative survey with parents

Appendix 6 Detailed description of methodology

Appendix 7 The structure of management team

Appendix 8 Full narrative report on in-depth interviews (complete)

Appendix 9 Full narrative report on focus groups (complete)

Appendix 10 Results of regression analysis

Appendix 11 Guide for reading tables

Appendix 12 Statistical tables – crosstabs with demography

.


Appendix 1

Results of internet search about safety of vaccines: illustration of the ratio of pro and antivaccination contents

181Appendices


Appendix 2

The list of internet contents about the fight against vaccination125

Websites and accounts of antivaccination associations on social networks:

UG " Građanska inicijativa za neobaveznu vakcinaciju", Serbia

http://vaccinesinfo.org/

https://www.facebook.com/groups/843060252456661/

Media figure of this movement, “dr” Slađana Velkov

https://www.facebook.com/dr.sladjana.velkov

Slađana Velkov invites for founding of civil initiatives for voluntary vaccination in the region:

https://www.facebook.com/notes/sladjana-velkov/gradjanska-inicijativa-za-neobav-eznu-vaccination/10152878749584974/

False scientific blogs that reveal dangers of vaccination:

Institute for natural medicine

http://www.vaccines.comyr.com/

http://www.ivonazivkovic.net/UZASI-VACCINATION.html

List of video clips 1. Conference Unjustified forced vaccination, with the list of reputable speakers from the region

https://www.facebook.com/notes/vaccines-info/lista-video-snimaka-i-regionalne-konfer-encije-neopravdanost-prisilne-vaccination/981425948633619

Petition for abolishing compulsory vaccination in Serbia has more than 20 000 signatures and it is the 8th most extensive petition of all times in Serbia

http://www.peticije24.com/peticija_za_ukidanje_obavezne_vaccination_u_srbiji

Legal advice for parents on how to avoid vaccination:

https://obaveznavaccination.wordpress.com/

YouTube channels about this topic: The truth about vaccines, Cure yourself on your own

Translated appearances of antivaccination-oriented professionals:

https://www.youtube.com/watch?v=SEeZa6pBPOE

1 The material was collected during November 2016.

183Appendices

https://www.youtube.com/watch?v=5KcFgp0ymMs

https://www.youtube.com/watch?v=1bkqY4vL_x4

Slađana Velkov appearances in the media

Kopernikus TV, “dr” Slađana Velkov: https://www.youtube.com/watch?v=PHEZZ6_uljM

TV Prva, “dr” Slađana Velkov: https://www.youtube.com/watch?v=XdlIrOLY6J4

Testimonials of parents of children with autism

https://www.youtube.com/watch?v=MexhYXJ0vVs

Kopernikus TV, local parents (16:00 min): https://www.youtube.com/watch?v=ymbK6v-Y9ek

local parents, children harmed by vaccines: https://www.youtube.com/watch?v=f0IjEAMVG5o

Documentaries, subtitled and made for local audience:

“The truth about vaccines”:

https://www.youtube.com/watch?v=QIHIt1HbW8M

“The truth about Serbian vaccination lobby” (especially from 50-60 min):

https://www.youtube.com/watch?v=Ep9mbcppgwg

NGOs against vaccination:

Appearance of the initiative for voluntary vaccination on TV PINK: https://www.youtube.com/watch?v=bFRiZRch3_o

The theory of conspiracy about vaccination

Mass chipping through vaccines:

http://webtribune.rs/covecanstvo-u-opasnosti-od-2016-pocinje-masovno-cipovan-je-putem-vaccination-video/

Eugenics through vaccines:

https://www.youtube.com/watch?v=nxh7B_OtwbA

Vaccines – pharmaco-mafia gets life-long customers:

https://www.youtube.com/watch?v=Ep9mbcppgwg


Appendix 3

Guide of interview with key informants ■ Please explain your own role in immunization process and process you are engaged in

■ What you think is the strongest and what the weakest link in immunization process with-in public health system in Serbia (public, media, leadership, public health institutes, leg-islation, or something else?)

■ How do you perceive current legislation regarding immunization (probe for responsibili-ty/accountability: vaccine procurement and distribution, availability of vaccines and oth-er supply (cold chain/syringes/needles), immunization schedule, reporting on adverse events, communicating with parents, parents’ consent)? Is there a need for change? Why? How?

■ How would you briefly describe the role of your institution and your own role in the pro-cess of immunization of population/children?

■ How do you communicate with other stakeholders in the process? Describe in detail. How would you rate cooperation and interaction with the other stakeholders?

■ What are the main barriers you typically face during the process of communication re-lated to immunization with other institutions (please describe)?

■ Are procedures (legal framework, guidelines and protocols) flexible enough to:

■ Allow space for “doctor’s decision” – e.g. health workers can apply procedure/solution that is in the best interest of the child (to your best knowledge) without fear on any con-sequences; and

■ Allow learning from mistakes? Please provide an example for yes/no.

■ Do you think that current vaccine supply is sufficient to meet the need of target population?

■ In case of vaccine shortage, can parents buy vaccines in local pharmacy?

■ the weakest link in the chain of immunization (if any): vaccine supply and cold chain (“refrigeration equipment to keep vaccines safe”), distribution, financing, communica-tion with parents, ability for outreach? Explain in detail (going from HC to community – e.g. reach Roma children in Roma settlements) and conditions in the room where im-munisation is performed which ensure safe immunisation and the least stress for the child and health workers? Please explain in detail.

■ Provide us with an example of specific issue you faced in previous 12 months that best describe current challenges or opportunities for immunization in Serbia. Was the prob-lem solved and how?

■ Have parents aver asked from you the expiry date or country of origin of the vac-cines which you wanted to administer to their child? Has any parent ever asked you for your opinion regarding instructions/printed instructions related to vaccine bought in lo-cal pharmacy?

185Appendices

■ Do you feel that you have enough information to respond to their questions? Do you feel that they are satisfied with the information you can provide?

■ Do you think your institution/team is doing well its part to make sure population is immu-nized? What about you personally? Do you feel your institution/team has enough say in the process? Have you ever discussed this with your team (nurse) and your supervi-sor? When was the last time your team attended training/consultation regarding immu-nization? Was this consultations for health workers only (or parents could participate?) When was the last time nurse working with you have attended training on immuniza-tion? In case you have any technical question, who is the person you can call (please indicate function and institution)? When was the last time you had direct communication with regional level immunization coordinator?

■ Do you think it should be changed and how?

■ How would you compare the whole process of immunization: legislation, procedures, their implementation, and communication with public in Serbia in comparison to the EU countries? What are the main differences? What changes in our system would you rec-ommend based on that?

■ How do you see communication between official institutions of public health and gen-eral public? Who is primary responsible for communication? Is there room for improve-ment? How should it be done?

■ Is there a public trust in public health system? Why yes/no? How do you think people form their opinions about it?

■ out vaccines/immunization? Please Provide examples.

■ Do you think there are misconceptions about immunization? (Probe for: vaccines can cause illnesses/have serious side effects, vaccines aren’t necessary for public health, vaccines are more dangerous than diseases, vaccines are given too early, too many vaccines are given at once)?What is the major misconception?

■ What do you think are sources of these misconceptions? Can they be addressed? How?

■ When was the last time you heard any misconception from a parent (mother/father of the eligible child)? What was the issue specifically? Have you discuss it with them? Where you successful?

■ What is the trend in general population when it comes to immunization – declining, stay-ing the same, increasing? Why? Identify the main reason?

■ Is immunization your major “service delivery” issue at present? Do you foresee it to be one? Why?

■ Do you think immunization should be only mandatory? Do you think that that would help you in communicating with parents/community? Please describe how?

■ What was your attitude to immunization consent forms? Was it useful? Why? Is it a problem for parents? Do you think consent forms were useful in periods were vaccines were in short supply?


■ How would you weigh the risks and benefits of immunization? Describe in detail.

■ Which are the most vulnerable groups with the lowest vaccination rates in your area? What is their major obstacle for vaccinating (for each group probe for availability, acces-sibility, passiveness, active decision not to vaccinate)?

■ To what extent should the beneficiaries (parents on behalf of children) be autonomous in deciding about immunization and other health related behaviour? Which decisions should be left for them to decide and which not? Why? How to make sure the user makes an informed decision? What are the consequences of uninformed decision mak-ing? Who do you see as primary responsible for it?

■ Have you heard of any organized or informal anti-vaccination group/individual in your area? Which ones? How have you heard about it?

■ What do you think of their impact on parents? Do you think citizens are susceptible to it? Which groups in particular? Why?

■ Can you state the main arguments of the anti-vaccination group/individual? What do you think of those arguments? Please explain.

■ How should public health sector respond to it?

■ Have you heard of any organized pro-vaccination group/individual? Which ones? What do you think about their activities?

■ What are your experiences with parents who come to inquire about vaccines? What questions do they ask? How do you answer? Do you change the way in which you address parents depending on their initial attitude towards vaccination, positive or negative?

■ Have you ever had any problems in communication with parents? Can we have any examples?

■ When do you address parents with topic of immunisation first? Before or after vaccination?

■ What are the basic information that you supply the parents with regarding vaccination of their children? Is this a routine part of your job or it involves some advisory component as well? Please provide an example.

■ In your opinion, who is the decision maker about vaccination of child, mother or father? Do you have an impression that this decision is made after long consideration or you think that parents do not think too much about it, but they see it as an inseparable part of their child’s health protection?

■ What is the main proven source of information which the parents rely on?

■ How do you dee the role of media in immunisation and public health (ask about press, TV, newspapers, Internet)? Example of professional /unprofessional media activities.

■ How do you see your role in communication with public? Can it be better? How?

■ Have you heard about any activities directed towards increase of awareness about the need for immunisation in general population or among parents (e.g. immunisation for

187Appendices

life, Immunisation week, round tables …)? What do you think about such activities? Are any of these activities included in the current plans of your institutions? Do you have any suggestions for improvement?

■ What would you suggest as the best way of communication with parents and public in general? Is it necessary to pay special attention to vulnerable groups? How?


Appendix 4

Guide for discussion in focus groups (general and Roma population)

■ Does/Do your child/children have a regular health care provider (regular – meaning pri-mary care physician or doctor that the child sees consistently for routine health care)?

■ Where do you usually take your child for health check-ups? How often and for what rea-sons? complaints? How many regular check-ups you need to have for your child and when? Do you regularly go to see the doctor or only when the child is seek? Did you ever receive the call from the local health care centre for the regular check-up for your child? (Probe for call for immunization)

■ How far from your house/apartment t is local health care centre? How do you go there? How convenient is for you to go there what your child?

■ Do you face any difficulties in accessing health care for your child/children?

■ Are you satisfied with the way you are treated in the local health centre? If you have ex-perience with other health institutions please explain the treatment you receive and how satisfied are you? Describe a typical experience? Did you ever have any unpleasant experiences? Did you have trouble getting the care for your child when needed? Please describe.

■ Does your child have health documents? Other family members? How did you obtain them or why didn’t you obtain them? Did you face any difficulties in the process? Please describe.

■ Did you ever take your child to a private practitioner? If yes, for what reasons? What fa-cility and why?

■ Do you know against which illnesses child gets immunized (what vaccines receives) before he/she goes to school? For probing: What are the most dangerous diseases from which people can be protected by vaccination (VPDs: Diphtheria, Polio, Measles, Tetanus, Tuberculosis, Whooping cough)?

■ Do you know the consequences of those diseases (e.g. polio leads to disability, etc.).

■ How do you perceive the risk for your child to be infected with those diseases?

■ What do you think is the best way to go about those diseases (immunization vs treat-ment)? What do you know about VPD (vaccine preventable diseases)outbreaks? Have you ever heard about VPD outbreak (either recent, or in the past)?Do you think that ep-idemic disease might affect you? What did that perception of outbreaks do to your de-sire to vaccinate?

■ Are you, at least provisionally, aware of the timeframe for immunization? Do you have immunisation schedule in writing/brochure with schedule ? Do you think it is important to follow this timeframe? Why yes/no? When is it allowed not to follow it?

■ Did you have your child/children immunized? Where do you take your child for immu-nization? Can you share some of your experiences when your child/children was/were

189Appendices

vaccinated? Did somebody from the local health provider ever call you and remind of immunization?

■ How did your child respond to vaccines? Do you know about the possible effects of the vaccination? Did your child ever have the negative effects after the vaccination? If yes, please describe the symptoms of your child and your feelings and practices? How old was your child when s/he received his/her first vaccination? When was the last time your last child was vaccinated? Which vaccine was s/he provided?

■ Do all children need to get immunized? Did you immunize all your children? Do you think some children should, and some shouldn’t get immunized? (PROBE for age, gen-der, health status, general vigilance, fear of needles)? Do you think that your child need to get all vaccines or only some of them? Why?

■ Did it ever happen that the vaccines weren’t available with the health care provider? How often? Could you describe the experience? What did you do? What did the nurs-es/doctors say to you?

■ Did you ever pay for a vaccine for your child? When? Why? Could you describe the experience?

■ Do you trust quality control of vaccines? Do you believe that vaccines purchased in pri-vate pharmacies are of higher quality than those distributed through health system?

■ Have you ever postponed vaccination? Did you decide to postpone or the doctor? Could you tell us more about the reasons for postponement?

■ Have you ever sign a consent form regarding vaccination? What was it for (refusal to vaccinate or acceptance to vaccinate)? Were you offered or did you ask for it? Why? Describe the experience.

■ Would you recommend vaccination to your friends/relatives? Why yes, why no? Is that for any particular vaccine? Which one?

■ What would you tell a Parent who has got doubts about to have her child vaccinated or not? Please describe.

■ Did you personally have any doubts about the safety of vaccination? If so, which ones? How did you deal with those? What do you think about them now?

■ In general, would you say immunization is necessary for children? Why yes/no? Which advantages/disadvantages do you see of immunization for the child? LIST ALL BENEFITS AND BARRIERS

■ In your opinion how effective are vaccines in protection of child from vaccine prevent-able diseases (VDPs)? What do you see as the risks of not taking your child to the im-munization? Does the child that is not vaccinated is a risk for your child?

■ What do you see as the risks of taking it? What do you think about vaccine safety? What are your major threats with respect to vaccines, if any?

■ What do you know about risks of vaccine side-effects? TO what extent do you agree that the benefits of vaccination outweigh the risks?

■ What do you think about alternative medical care (naturopathic, homeopathic, allopath-ic)? Have you ever used them as alternative to vaccination?


■ Do you take herbal supplements, teas, home-made ointments instead of going to the doctor? Have you ever used them as alternative to vaccination?

■ Do you think they can be efficient substitute for vaccination? Which ones?

■ Do you think in some situations it is not wise to vaccinate a child? Which ones? (probe: when ill, when of general bad/good health, when it’s not exposed to illnesses)

■ What do you think of children receiving multiple vaccines in the same visit? What about combination vaccines (vaccines for different illnesses in one shot)?

■ Do you trust Serbian mechanism for quality control of vaccines? Why yes, why no? Who do you trust the most? Do you trust local or foreign vaccines more? Did you change al-ways have the same degree of trust or you change your opinion?

■ What is your opinion about vaccine contraindications?

■ How did you reach your final decision about vaccinating your child? Was it a difficult de-cision? Why yes-no? What was the main argument for that decision?

■ Did you consult with other people prior to having your child/children vaccinated? If so, who with? What questions do you ask? To whom do you trust most?

■ Do you make the decision by yourself to have your child/children vaccinated or with the other parent of the child or both together? (PROBE for: mother’s decision, father’s deci-sion, decision of other senior members of the family) Did you discuss the issue with oth-er family members? Or you only listen and behave according to doctors suggestions?

■ Do you listen and behave according to doctors suggestions? Or you always gather ad-ditional information about vaccination?

■ Do you feel you know enough about vaccination? Would you like to know more?

■ Did you feel competent to decide whether to have your child vaccinated?

■ When you take your child to the doctor (PHC provider), did he doctor talk to you about immunization?

■ What did the doctor say about child vaccination? Who initiated the conversation about vaccination (you or the doctor)?

■ In general, to what extent do you think the doctor provides you with useful information about child vaccination? What attitude does the doctor have when talking to you? Was the doctor patient?

■ Did he/she talk to you so you could understand?

■ Did you feel free to ask questions? Why yes/no? Were you given the answers? Were you happy with the answers doctor gave you? Do you trust what your doctor says or you prefer to check information with someone else? If so, with whom?

■ Now, I will read you the post from a mother on an online parenting forum:

Dear moms, here is my experience!!!My son was nearly 13 months old when he received his MMR vaccine. After two weeks he got fever which lasted for 2 – 3 days...I took him to health care centre and they told me that it was because of teething...One week later, or three weeks after the vaccine he developed a big swelling under left ear in the direction of cheek. Under

191Appendices

my fingers I felt swollen glandules...I took him to primary health care centre again and they told me that this was a reaction to vaccine, not to worry, just to care that it didn’t become worse...They reported my case to Belgrade as vaccine side effects and that was it...They also checked his blood and found a virus in the body, which they considered normal....After two days new glandules appear on his neck and head, also on the left side...A week passed, the swelling shrank gradually, but the glandules are still there...I’ve read a lot of t0hings here and I don’t believe what our children go through in this country...Not to forget that before vaccination no one warned me about the possibility of such reaction...Now I wonder wheth-er this is normal...are we cattle, are our children guinea pigs...is there any sense in this!!!! I hope that we will be OK, and I’ll let you know about the new developments... Greetings to all the anxious mothers!!!!

■ What was the text about? Please re-tell in one or two sentences?

■ What do you think about it? How does it make you feel? What would you say to this par-ent? Can you relate to her concerns? Do you find them justified? Why yes/no?

■ Are you acquainted with parents who decided not to have their children vaccinated?

■ How many of those are, approximately, in your social circle?

■ Did you ever hear some stories about negative effects of the vaccines? Please share.

■ How did you hear about this? What do you think about it? Do you think it is true?

■ How common do you think cases like this are? Did it affect your decision to vaccinate? Why yes/no? Would you say that non-vaccinating is a growing or declining trend?

■ Have you ever read any media contents related to vaccination? Which ones?

■ How do you search for information? Which sources do you trust, and which sources you do not trust? Why?

■ Which arguments for or against immunization did they use? Did you find these argu-ments persuasive? Why yes/no? (Probe specifically for: Internet sources, Social net-works, Parenting blogs and forums – which ones, their opinion about them)?

■ Which sources do you trust the most for information on vaccination?

■ Do you have any questions or confusion relating to vaccines right now that you can mention? If so, why did you not ask your doctor?

■ Now, I will read you again the post from a mother on an online parenting forum:

I have recently been in a situation to decide whether to have my children vaccinated (MMR). I wasn’t even thinking whether or not to vaccinate Andrija, but in the meantime, my friend’s son (of Andrija’s age) became autistic. This broke me down completely, especially because it’s a very severe form. I feel responsible to share with you the conversation I had with my paediatrician before I had my children vaccinated (a man with 35 years of work experience, very much informed about everything associated with vaccination). He says that no theo-ry has been proven, but he is a member of the Committee for children with developmental disabilities and he says that 10 out of 3 500 children suffer from autism. He claims that this number would have been a lot bigger if it were triggered by vaccines. He also says that the viruses that MMR is used for have mutated so much that little children either wouldn’t sur-vive or would survive with severe consequences (vaccination used to be skipped during the war and it left fatal consequences). He believes that autism is genetically predisposed,


and it is associated with vaccines because the first signs of autism usually appear during the vaccination period. The doctor told me that he had his children vaccinated ad that he will also have his grandchildren vaccinated too. This conversation really calmed me down, so I decided to keep on with vaccination. Perhaps someone may find this text useful when making this decision.

■ What was the text about? Please re-tell in one or two sentences? What do you think about it? How does it make you feel?

■ Do you find these arguments persuasive? Would you trust this doctor? Why yes/no?

■ What is the general attitude toward vaccination in Serbia? Why? Who do you see re-sponsible for this?

■ In your opinion getting your children vaccinated is the normal, expected behaviour for families like yours?

■ Would you tell other people that you vaccinated/did not vaccinate your child? What do you think their reaction would be? Why?

■ Does the vaccination status of your child tell anything about you as a parent (good or bad)?

■ How many of your relatives/friends vaccinate their children? Why yes/not?

■ What are your family/friends opinion regarding vaccination?

■ What do you think is your doctor’s attitude?

■ In what extend do your spouse (husband/wife) and child’s grandmothers encourage or discourage vaccination? What about other families?

■ On what extent mass media, including the Internet, encourages or discourages vaccination?

■ Have you seen in your HC or at the private doctor some materials regarding vaccination?

■ At the end, what would you say, do you feel informed about vaccination? Why yes, why no?

■ Would you like to get more information about this topic? How? (ask for: pamphlets, or-ganized workshops or classes for parents in your HC, community...) What else would you need to help you while deciding about immunization? More information from the doctors/experts/ leaflets/consultations with experts...

193Appendices

Appendix 5

Questionnaire for quantitative survey with parentsGood morning/day/evening, my name is __________________ . I am working as an interviewer in research agency Ipsos Strategic Marketing which regularly conducts surveys on various topics. I would appreciate if you answered some questions to me. The survey is statistically anonymous and all obtained data will be presented in cumulative form and used only for the purposes of this project.

Screener

Sel1 Is respondent ROMA? 1. Yes 2. No Dem1

Dem1 Gender: 1. Male 2. Female

Dem2 Age):

Dem7c

Total number of children in household (age below 18) If no: END

Children in pre-school age (up to 7 years old, we do not count on age 7) If no: END

Children in elementary school (7 to 14 years)

High school children (from 15 to under 18)

A1 Vaccination experience INT: Now I will ask you few questions about your experience as a parent regarding vaccination of a child. If you have more than one child, please think about your experience with your youngest child. I will let you know when we are talking about your all children

A2A1 Which of the following is true for your child (if more children, for your youn-gest child)

INT] Single answer. Show card

3. I took him/her to get vaccinated following the calendar for mandatory vaccinati-on.

4. I was hesitant to take him/her and delayed in getting some mandatory vaccines.5. I allowed him/her to get vaccinated for some, and refused other mandatory vac-

cines.6. My child did not get any vaccines DK, Refusal (don’t read) A2

A3A2 IF A1=4, d (don't read) on't ask

Now we will talk about your experien-ce when you took your youngest child to vaccination.

Please recall the last time you took your child for a vaccination (if more than one child, respond for the youn-gest child that has been vaccinated).

Try to remember it in as many details as you can. Next, answer if these hap-pened to you/your child:

Yes (It happe-

ned)

No (Not happe-

ned)

Don't know, refusal

(don't read)

A3

1.I took myself a child to vaccination, according to the vaccination calendar 1 2 99

2. I was called on the phone by the health officials when my child needed to be vaccinated.

1 2 99

3. I received a written notification on my address from the health officials infor-ming me that my child needed to be vaccinated.

1 2 99

4. My child’s paediatrician informed me about the next date for vaccination my child needs to receive.

1 2 99


First, we will ask you about how you were informed about the vaccinati-on, and then what kind of experience you had on the last time you took your child to vaccination.

INT] Single answer per row. Show card

5. I had a question about vaccines that I did not get an answer to.

1 2 99

6. I was given vaccination calendar in a healthcare institution

1 2 99

7. I waited for a long time (more than half an hour) for a vaccine in the health centre.

1 2 99

8. There were no vaccines in the health centre.

1 2 99

9. My child was examined by paediatrician for health status before vaccination

1 2 99

10. My child’s paediatrician informed me about the disease my child is getting vaccinated against.

1 2 99

11. My child’s paediatrician informed me about the potential side-effects from the vaccine.

1 2 99

12. My child’s paediatrician instructed me how to react in case my child gets any adverse reaction.

1 2 99

13. My child had a mild adverse reaction (swelling, temperature) to vaccine that cleared quickly and did not require any medical help.

1 2 99

14. My child had a severe adverse reaction to vaccine that needed to be treated medically and reviewed and reported by professional team.

1 2 99

15. In general, my experience with vaccinati-on was positive.

1 2 99

A4A3 If Dem7ca> 1

Now I ask you to think about all your children, and again we are talking about your general experience when you took your children to vaccina-tion. Now, we are talking have the following things EVER happened to you?


Yes (It happe-

ned)

No (Not happe-

ned)

Don't know, refusal

(don't read)

A4

1. I didn't vaccinate any of my children 1 2 99

IF A3.1 =1, don't ask2. I took myself a child to vaccination,

according to the vaccination calendar1 2 99


1 2 99


1 2 99


1 2 99


1 2 99

195Appendices

First, we will ask you about how you were informed about the vaccinati-on, and then what kind of experience you had on the last time you took your child to vaccination.



1 2 99


1 2 99

7. I waited for a long time (more than half an hour) for a vaccine in the health centre.

1 2 99

8. There were no vaccines in the health centre.

1 2 99

9. My child was examined by paediatrician for health status before vaccination

1 2 99

10. My child’s paediatrician informed me about the disease my child is getting vaccinated against.

1 2 99


1 2 99

12. My child’s paediatrician instructed me how to react in case my child gets any adverse reaction.

1 2 99

13. My child had a mild adverse reaction (swelling, temperature) to vaccine that cleared quickly and did not require any medical help.

1 2 99

14. My child had a severe adverse reaction to vaccine that needed to be treated medically and reviewed and reported by professional team.

1 2 99

15. In general, my experience with vaccinati-on was positive.

1 2 99

A4A3 If Dem7ca> 1

Now I ask you to think about all your children, and again we are talking about your general experience when you took your children to vaccina-tion. Now, we are talking have the following things EVER happened to you?


Yes (It happe-

ned)

No (Not happe-

ned)

Don't know, refusal

(don't read)

A4

1. I didn't vaccinate any of my children 1 2 99

IF A3.1 =1, don't ask2. I took myself a child to vaccination,

according to the vaccination calendar1 2 99


1 2 99


1 2 99


1 2 99


1 2 99

7. My child’s paediatrician informed me about the next date for vaccination my child needs to receive..

1 2 99

IF A3.1 =1, don't ask8. I waited for a long time (more than half an

hour) for a vaccine in the health centre.1 2 99

IF A3.1 =1, don't ask9. There were no vaccines in the health

centre.1 2 99

IF A3.1 =1, don't ask10. My child was examined by paediatrician

for health status before vaccination1 2 99

11. My child’s paediatrician informed me about the disease my child is getting vaccinated against..

1 2 99


1 2 99

IF A3.1 =1, don't ask13. My child’s paediatrician instructed me how

to react in case my child gets any adver-se reaction.

1 2 99

IF A3.1 =1, don't ask14. M My child had a mild adverse reaction

(swelling, temperature) to vaccine that cleared quickly and did not require any medical help.

1 2 99

IF A3.1 =1, don't ask15. My child had a severe adverse reaction

to vaccine that needed to be treated medically and reviewed and reported by professional team.

1 2 99

IF A3.1 =1, don't ask16. In general, my experience with vaccinati-

on was positive.1 2 99

A3 For Roma population, if Sel1=1

Was there ever a campaign for vacci-nation in your community INT] Single answer

2. Yes3. No (skip on A6)(Don't know, refusal – don't read) 1 2 99

A5

A4 For Roma population, if Sel1=1 and if A5=1Have you vaccinated any of your children as a result of vaccination campaign in your community?INT] Single answer

4. Yes5. No (Don't know, refusal – don't read)

1 2 99

A6

A5 For Roma population, if Sel1=1 and if A5=1In healthcare institutions, many unpleasant things happen to many people.

Yes (It happe-

ned)

No (Not happe-

ned)

Don't know, refusal

(don't read)

A71. Doctors or nurses were rude to me or my

child. 1 2 99


Now, I'm going to read some of the situations that are happening often, and can you please tell me whether you have personally experienced any of these situati-ons?


13. Doctors or nurses refused to treat my child. 1 2 99

14. I was left to wait longer than the others. 1 2 99

15. I was spoken to in a manner that I did not understand. 1 2 99

16. I was told by doctors or nurses that I am not a good parent. 1 2 99

A8A7 For Roma population, if Sel1=1

Now, please, re-think about the experiences with your youn-gest child. Tell me if any of the following applies to your youn-gest child?


Yes (It happe-

ned)

No (Not happe-

ned)

Don't know, refusal

(don't read)

B1

17. My child has a medical ID 1 2 99

18. It was (is) difficult to get medical IDs for my child. 1 2 99

19. I could not get the child vaccinated on time because I had no one to leave other children.

1 2 99

20. I could not get the child vaccinated on time because I wasn’t sure what I was supposed to do and when..

1 2 99

21. I could not get the child vaccinated on time because I forgot about it. 1 2 99

22. I could not get the child vaccinated on time because the medical care centre is hard for me to reach (too far).

1 2 99

23. I could not get the child vaccinated on time because there was no one to accompany me to the health centre.

1 2 99

24. I could not get the child vaccinated on time because transport to the health care centre is too expensive for me

1 2 99

25. I could not vaccinate the child on time because the child did not have a medical, health record (or had no chosen doctor).

1 2 99

A9A8 For Roma population, if Sel1=1

Now, we will talk about a health mediator- - that is, a person who needs you and your child to help with treatment in health facilities (health centre, hospitals). Would you please tell me if the following claims relate to your experiences with a medical mediator?


Yes (It happe-

ned)

No (Not happe-

ned)

Don't know, refusal

(don't read)

There is a health mediator active in our community. 1 2 99

If NO_ Section

B

I know the name of the health mediator in our community. 1 2 99

The health mediator regularly visits our family. 1 2 99

197Appendices

The health mediator reminds us about the dates for vacci-nation. 1 2 99

The health mediator offers help to get child vaccinated.

1 2 99

B Vaccine Attributes, Vaccine Profit and Vaccine Analysis, Intentions for Child Vaccination

INT: We are continuing the story of the vaccines. We'll talk about what some of the views of the vaccination of children are, and you tell me to what extent these visions are close to yours.

A10B1

Now, I will read some sta-tements. Please tell me to what extent you personally agree with them using the scale from 1 to 5, where 1 means that you do not agree with any claim at all, and 5 that you fully agree with it.


Not agree at

allMostly

not agree

I neither agree

nor disa-gree

Mostly agree

Comple-tely

agree

Don't know, refusal (don't read)

B5

1. I am worried about the side effects of vaccines. 1 2 3 4 5 99

2. I am worried that vac-cines can trigger other diseases 1 2 3 4 5 99

3. I am worried about the multiple vaccines in one take.

1 2 3 4 5 99

4. I am worried that chi-ldren are exposed to vaccines too early. 1 2 3 4 5 99

5. I am worried about the quality of the vaccines that are being admini-stered to my child.

1 2 3 4 5 99

6. I am worried that my child can get disease if not vaccinated. 1 2 3 4 5 99

7. I am worried about the possible outbreaks of vaccine preventable diseases.

1 2 3 4 5 99


8. I am worried about the consequences of more parents refusing to vaccinate their chi-ldren.

1 2 3 4 5 99

9. All in all the vaccinati-on is useful.

1 2 3 4 5 99

10. According to my opini-on, vaccination should be mandatory 1 2 3 4 5 99

11. I am hesitating to vac-cinate my child becau-se it is mandatory. 1 2 3 4 5 99

12. There should be legal consequences for parents who refuse to vaccinate their children.

1 2 3 4 5 99

A11B2

We continue with the sta-tements. Please tell me to what extent you personally agree with them using the scale from 1 to 5, where 1 means that you do not agree with any claim at all, and 5 that you fully agree with it.


Not agree at

allMostly

not agree

I neither agree

nor disa-gree

Mostly agree

Comple-tely

agree


C1

13. Vaccine against MMR causes autism.

1 2 3 4 5 99

14. Preservatives in the vaccines are toxic (poi-sonous). 1 2 3 4 5 99

15. Combination vaccines are only marketing trick of pharmacy sector 1 2 3 4 5 99

16. The vaccines impor-ted in Serbia are of lower quality. 1 2 3 4 5 99

199Appendices

17. The quality check of the imported vaccines is not good enough 1 2 3 4 5 99

18. It is better to wait for the child to be older and to strengthen, and then vaccinate it. 1 2 3 4 5 99

19. All viral “rash” dise-ases are essentially harmless. 1 2 3 4 5 99

20. The diseases that are mandatory to vaccinate against are mild dise-ases. 1 2 3 4 5 99

21. There is no real dan-ger of an outbreak of the vaccine preventa-ble diseases in Serbia. 1 2 3 4 5 99

22. Modern medicine can more easily cure diseases that can be prevented by the vac-cine than it can cure unwanted consequen-ces of vaccination

1 2 3 4 5 99

23. Too many vaccines are given to the children and this will hamper my child’s immunity

1 2 3 4 5 99

24. It is better for the child to overcome the disea-se and thus strengthen immunity, rather than being vaccinated.

1 2 3 4 5 99

25. Only the first dose of vaccine is important, other doses (re-vacci-nation) are optional. 1 2 3 4 5 99


C Social support for vaccine, norms, beliefs

A12

C1

And what would you say, to what extent do peo-ple in your environment support vaccination or oppose vaccination? Again, please use a scale of 1 to 5, 1 means that you think they are com-pletely opposed to the vaccination, and 5 fully support the vaccination


They abso-lutely

oppose it

Somewhat oppose it

Nor are they

oppo-se or

support it

Somewhat support it

They abso-lutely

support it


C6

26. Family1 2 3 4 5 99

2. Close friends1 2 3 4 5 99

3. Healthcare workers1 2 3 4 5 99

4. Other parents 1 2 3 4 5 99

5. Media1 2 3 4 5 99

D1

6. My religion beliefs1 2 3 4 5 99

7. Only for Roma: Leaders of the Roma community

1 2 3 4 5 99

A13

C2

Please tell me to what extent you personal-ly agree with them us-ing the scale from 1 to 5, where 1 means that you do not agree with any claim at all, and 5 that you fully agree with it.


Not agree at

allMostly

not agree

I neither agree

nor disa-gree

Mostly agree

Comple-tely

agree


27. If I don’t vaccinate my child that would make me an irresponsible parent.

1 2 3 4 5 99

D7

28. Getting your child vaccinated is expected behaviour from families like mine.

1 2 3 4 5 99

29. By vaccinating my child I am contributing to the health and welfare of my society

1 2 3 4 5 99

D Channels of information

A14

D1

How often do you get health related informa-tion through the fol-lowing channels?


Never Rarely Some-times Often Always


201Appendices

30. TV1 2 3 4 5 99

D2

31. Newspapers, print media 1 2 3 4 5 99

32. Radio1 2 3 4 5 99

33. Official Internet sites

1 2 3 4 5 99

34. Forums, blogs1 2 3 4 5 99

35. Social media1 2 3 4 5 99

36. Health providers1 2 3 4 5 99

37. Friends, family mem-bers, other parents 1 2 3 4 5 99

A15

D2

And to what extent do you trust to each of this channels? Please use the scale from 1 to 5, where 1 means that you don't trust them at all, a 5 that you trust them completely.

A list of the media for which the respondents say every-thing except 1 is shown.

I don't trust at

all

Somewhat I don't trust

Neither I trust them

neither I don't trust them

Somewhat I trust

I comple-tely trust


38.1 2 3 4 5 99

D3

2.1 2 3 4 5 99

3.1 2 3 4 5 99

A16

D3

And do you use the fol-lowing sources of infor-mation to inform yourself about the vaccination?


Yes No


If yes: Which ones

E1

39. TV

1 2 991st place, 2nd place, 3rd place DK, Ref (don't read)

40. Newspapers, print media


41. Radio



42. Official Internet sites


43. Forums, blogs


44. Social media


45. Health providers


E Beliefs

A17

E1

Different people have different opinions about vaccination. I will read from you some of these opinions, and you tell me how you think the ex-tent to which these opin-ions or claims are true.


Certainly not

Probably not

Yes and no

Probably yes

Certainly yes


D8

46. Vaccine safety data is often fabricated

1 2 3 4 5 99

47. Immunizing children is harmful and this fact is covered up. 1 2 3 4 5 99

48. Pharmaceutical com-panies cover up dan-gers of the vaccines 1 2 3 4 5 99

49. People are deceived about vaccine safety

1 2 3 4 5 99

50. Vaccine efficacy data is often fabricated

1 2 3 4 5 99

51. The government is trying to cover up the link between vaccines and autism

1 2 3 4 5 99

52. Domestic vaccines are better than imported

1 2 3 4 5 99

203Appendices

F Future vaccine behaviour

A18

F1

We will now discuss the compulsory vaccines that your child should receive according to the vacci-nation plan. How will you behave in the future when it comes to your child (if there are more chil-dren, the youngest child)

INT: Single answer

53. I will certainly get him/her vaccinated following the schedule.54. I will probably get him/her vaccinated following the schedule.55. I will get him/her vaccinated for some vaccines, and refuse the others.56. I will refuse to get him/her vaccinated at all.Don't know, refusal – don't read

G1

G Information and knowledge about vaccination

INT : Now, I will ask you a set of vaccination questions. Most parents do not know the exact an-swers to these questions and you are not expected to know the answers to all these questions..

A19

G1

What would you say, how much are you informed about vaccination?

INT Single answer.

57. Completely uninformed58. Somewhat uninformed59. Neither informed nor uninformed 60. Somewhat informed61. Completely informedDon't know, refusal – don't read G2

A20

G2

Do you know how vaccination protects against disease?

INT Single answer.

62. Inserting a small amount of the infective agent, to trigger immune response63. inserting antibodies that help fight antigens/infective agents64. inserting autoimmune microorganismsDon't know, refusal – don't read

G3

A21

G3

Some groups of chil-dren should NOT be immunized. What groups are those?

INT Multiple answers.

65. Prematurely born children 66. Children born with a disability 67. Low birth weight children68. Children with fever above 38.5 C 69. Children with diagnosis of compromised immune system70. Children who are allergic to some ingredients in vaccines 71. All mentioned groups of children Don't know, refusal – don't read G4

A22

G4

Do you know against which disease is BCG vaccine?

INT Single answer.

72. Tetanus73. Polio74. Measles 75. Tuberculosis Don't know, refusal – don't read G5

A23

G5

Do you know against which diseases is MMR vaccine?


76. Tetanus 77. Polio 78. Bronchial asthma 79. Mumps80. Measles 81. Rubella82. TuberculosisDon't know, refusal – don't read G6

A24

G6

Do you know against which diseases DiTePer vaccine?


83. Diphtheria84. Pertussis85. Tetanus86. Dysentery87. Peritonitis88. Tuberculosis Don't know, refusal – don't read G7


A25

G7

Do you know what the best timeline for the vaccination is?

INT Single answer.

89. All compulsory vaccinations should be given at the maternity clinic, immediately after the birth of the child

90. All mandatory vaccines should be taken until 15 months of age, all that follow are re-vaccines91. All mandatory vaccines should be taken by the age of five, all that follow are re-vaccines92. There is no recommended timeline – it makes no difference when the vaccines are takenDon't know, refusal – don't read

G2

A26

G8

Do you know what re-vaccination is?

INT Single answer.

93. Repeating vaccination if previous one was not successful94. Giving another dose of vaccine to make disease immunity get stronger and last longer95. Scar left on the skin by vaccinating96. A more advanced vaccine type that replaces the old oneDon't know, refusal – don't read

G3

H Internet behaviour

More and more people are being informed using the Internet. Think about how you act on the Internet.

Again, we use a scale of 1 to 5, but now 1 means you never act in a cer-tain way, and 5 that you always behave like that.

INT Single answer per row.

Never Rarely

Some-times yes,

some-times no

Often Always

I don't use

internet (don't read)


I1

97. I am searching for the author of the text 1 2 3 4 5

98 (Go to

i1)99

98. I am searching for different sour-ces of the same information on the Internet

1 2 3 4 5 98 99

99. I am thinking if the author of the text has an inte-rest to represent a certain viewpo-int

1 2 3 4 5 98 99

100. I “pick up” basic information and discuss them with friends

1 2 3 4 5 98 99

101. I read the title – the text is anyway mere repetition of the title

1 2 3 4 5 98 99

102. I am capable of reading the news only in my native language.

1 2 3 4 5 98 99

205Appendices

I Trust

A28

I1

Again, I will read some of your claims, and I ask you how much I believe that they are true. I'll show you the scale from 1 to 11, where 1 means that the statement is cer-tainly not true, and 11 that it certainly is

INT] Single answer

103.

Cer

tain

ly n

ot

2 3 4 5 6 7 8 9 10

104.

Cer

tain

ly y

es

Don'

t kno

w, re

fusa

l (d

on't

read

)

I2

1. I think that many very important things happen in the world, which the public is never informed about.

1 2 3 4 5 6 7 8 9 10 11 99

2. I think that politi-cians usually do not tell us the true motives for their decisions.

1 2 3 4 5 6 7 8 9 10 11 99

3. I think that gover-nment agencies closely monitor all citizens.

1 2 3 4 5 6 7 8 9 10 11 99

4. I think that events which superficially seem to lack a connection are often the result of secret activities

1 2 3 4 5 6 7 8 9 10 11 99

5. I think that there are secret organizations that greatly influence

1 2 3 4 5 6 7 8 9 10 11 99

A29

I2

Now we will ask you about how much trust you have in different institutions or treat-ment methods. We are interested in your personal opinion, there are no correct and wrong answers.

Again, we will use the scale from 1 to 5, where 1 means you do not trust them at all, and you 5 trust them completely.

INT] Single answer

I don't trust at

all

Somewhat I don't trust

Neither I trust them neither I

don't trust them

Somewhat I trust

I com-pletely trust


J1

106. Your paediatrician in health centre 1 2 3 4 5 99

2. Your paediatrician in the private sector (if you have one)

1 2 3 4 5 99

3. Nurses (medical stuff other than doctors)

1 2 3 4 5 99

4. Health system in Serbia 1 2 3 4 5 99

5. Pharmaceutical industry 1 2 3 4 5 99

6. National Agency for Quality Control of Medicines and Vaccines

1 2 3 4 5 99

7. Alternative medicine (homeopathy, acu-puncture, Reiki and similar)

1 2 3 4 5 99


8. Traditional medicine (herbal teas, ointments and similar)

1 2 3 4 5 99

9. Official medi-cine 1 2 3 4 5 99

J Attitude toward science

A30

J1

To what extent do you agree with the following claims? Again, we use a scale of 1 to 5, where 1 means that you do not agree with that state-ment at all, and 5 that you fully agree with it

INT] Single an-swer. Show card

Not agree at all

Mostly not agree

I neither agree nor disagree

Mostly agree

Comple-tely

agree

Don't know, refusal

(don't read)

K1

107. I am amazed by the achie-vements of modern science.

1 2 3 4 5 99

2. I think scientific method is the only reliable way of finding the truth about the world.laženje istine o svetu.

1 2 3 4 5 99

3. I doubt in the motives of scientists nowa-days.

1 2 3 4 5 99

4. I think that science will find the cure for most currently incura-ble diseases in the future.

1 2 3 4 5 99

K Preferred communication tools

A31

K1

Finally, tell me if you would like to receive in-formation about vac-cines in one of the following ways?


Yes No


If at least two claims have YES: Ask: You have been told that you would like to receive more infor-mation about the vaccination. Can you rank these ways from the one you like in the first place, on the second, and on the third.

Dem5

108. Written broc-hures in health centres that can be taken home.

Only two answers

1.

2.

Three:

1.

2.

3.

2. Posters in health centres that can be read while waiting.

207Appendices

3. A telephone line that can be called for vaccine-rela-ted questions.

1 2 99

More than three

1.

2.

3.4. TV debates on vaccination with experts.

1 2 99

5. Parental forums, blogs. 1 2 99

6. Websites offering a possibility to pose online questions to paediatricians, immunologists etc.…

1 2 99

7. Parenting seminars (“Škole roditelj-stva“) to address vaccination.

1 2 99

8. More time allowed to spend talking to my paediatri-cian

1 2 99

9. Roma only: For a doctor to come to our community and vaccinate the children on the spot.

1 2 99

Other, please specify _________ 1 2 99

Demography V1

Dem5

Education – last fin-ished school:

[INT] Show card Dem5.

1. Incomplete primary school2. Complete primary school3. Incomplete secondary school4. Incomplete secondary school, completed

trade school

5. Completed secondary school6. Incomplete faculty7. Completed college8. Completed faculty

Dem6a

Current occupation: Employed in a private or state company:

1. Unskilled worker2. Skilled worker (nurses, dri-

vers, teachers with college degree, soldiers, bakers, con-fectioners...)

Self-earning:

7. Highly qualified intellectual who is self-employed (lawyer, doctor, teacher …) – manda-tory faculty diploma

Unemployed:

12. Pupil 13. Student14. Housewife15. Maternity leave16. Pensioner


Current occupation: 3. White-collar (administration etc.)

4. Highly qualified intellectual (lawyer, doctor, teacher…)

5. Middle executive manager6. Top executive manager

8. Owns a small company, workshop etc. – less than 20 employees

9. Owns a big company, stockholder – more than 20 employees

10. Farmer, fisherman11. Earns in some other way

17. Unemployed (currently)18. Other, please specify?:

Dem7a

Type of household: 1. Lives alone2. Married couple with children

3. Married couple with grown-up children (over 27 years of age)

4. Multigenerational family

5. Single parent6. Married couple, children live

separately95. Other, please specify:

Dem7b

Total number of household members

Dem8c

Please rate the financial situation of your house-hold on a scale of 1 to 5:

[INT] Show card Dem8c

1 we don't have money for our basic needs2 3 45 money is not problem at allREF (Refusal)

Dem9

Nationality 1. Serbian2. Hungarian3. Bosniak4. Muslim5. Albanian6. ROMA95. Other______________________REF (refusal)

H5 For partner: Education – last finished school:

[INT] Show card H5

1. Incomplete primary school2. Complete primary school3. Incomplete secondary school4. Incomplete secondary school, com-pleted trade school

5. Completed secondary school6. Incomplete faculty7. Completed college8. Completed faculty

H6a For partner: Current occupation:

Employed in a private or state company:

1. Unskilled worker2. Skilled worker (nurses, dri-

vers, teachers with college degree, soldiers, bakers, confectioners...)

3. White-collar (administration etc.)

4. Highly qualified intellectual (lawyer, doctor, teacher…)

5. Middle executive manager6. Top executive manager

Self-earning:

7. Highly qualified intellectual who is self-employed (lawyer, doctor, teacher …) – manda-tory faculty diploma

8. Owns a small company, workshop etc. – less than 20 employees

9. Owns a big company, stockholder – more than 20 employees

10. Farmer, fisherman11. Earns in some other way

Unemployed:

12. Pupil 13. Student14. Housewife15. Maternity leave16. Pensioner17. Unemployed (currently)18. Other, please specify?:

209Appendices

Appendix 6

Detailed description of methodology – recruitment process for focus group discussions

Recruitment for focus group discussions

Recruitment of participants for focus group discussions was realised by recruitment team of Ipsos Strategic Marketing from Belgrade. Recruitment team had some criteria defined by research team and the Client on the basis of which it recruited potential participants. Table 4.1.3. features a short description of recruitment process.

The first step Defining the target groups in cooperation with the Client

The second step

Creating a screening questionnaire based on agreed criteria

Screening questionnaire includes questions referring to general conditions that need to be fulfilled in terms of recruitment process, and these questions refer to all types of research, plus there are questions pertaining to concrete project.

General conditions for selection of FGD participants are the following:

■ Participants (or their close friends or relatives) are not employed and not experts in the areas which are relevant for topic of the survey.

■ Participants did not participate in focus groups with similar topic during the preceding 12 months.

■ Participants do not know each other (haven’t met before FGD).

Specific criteria for selection of participants in focus groups in this survey were:

■ That participant is a parent of child aged from 0 to 7 years

■ That participant has positive/negative attitude towards vaccination, i.e, that participant’s child received all vaccines in time and participant has positive attitude on vaccination /postpones at least one vaccine on purpose

■ That participant is from urban/rural parts of the town

■ For Roma population: besides the previously mentioned conditions that parents are representatives of Roma population.

The third step

Trained interviewers recruit potential participants. Number of recruited participants is always bigger than final number of participants in FGD.

Final selection of participants is the task of supervisor who contacts potential participants in focus group discussions by phone and checks whether the recruited participants are appropriate candidates for FGD according to given criteria. Selected respondents receive information about place and time of focus groups.

Minimum two additional participants are invited to participate in focus group to ensure that the group will be complete even if someone fails to appear. In case that all invited participants appear, 8 participants who comply the most with the given criteria are selected. Candidates who are not chosen to participate are given an incentive for their time and effort, and the reason for not participating in FGD is explained to them adequately. At the end of the focus group all participants receive incentive in form of voucher for purchase in retail chains. More about incentives is explained within section Research ethics.

Table 4.1.3 – Process of recruitment of participants for FGDs


Detailed description of methodology – respondents in in-depth interviews

Key informants (realised a total of 8 interviews)

Representative of Health Ministry – 1 interview

Representative of Institute for Public Health „Dr Milan Jovanović Batut“ – 1 interview

Representatives of Institute for Public Health Belgrade, Novi Sad and Kraljevo – 3 interviews

Representative of League for Immunisation – 1 interview

Representative of Association of Parents – 1 interview

Representative of Association of paediatricians – 1 interview

Health workers (realized a total of 16 interviews) Belgrade Niš Novi Sad Požarevac

Paediatrician 1 1 1 1

Paediatric nurse 1 1 1 1

Visiting nurse 1 1 1 1

Roma mediator 1 1 1 1

Table 4.1.4 – Structure of in-depth interviews

211Appendices

Detailed description of methodology – quantitative survey

Location: Serbia

Data collection method: „Face-to-face“ interviewing in respondents’ households

Sample universe: Parents (mothers) of children 0 to 7 years old

Statistical documentation used for sample design:

Census 2011

Population excluded from the sampling

process:

Residents of areas hard to reach, remote parts of the country, imprisoned citizens, citizens placed in corrective institutions – 0.5% of the population is excluded from the sample

Sample frame:

Polling station territories (approximate to the size of Census block areas) within strata defined by region and type of settlement (urban and other settlements).

Explanation: Polling station territories enable the most reliable sample selection, since these units have the most complete and the most updated data. These data were updated last before the 2014. elections.

Type of sample: Two-stage random representative stratified sample

Sample stratification:

First stage of stratification: Belgrade, Vojvodina, Šumadija, West Serbia, East Serbia and South Serbia

Second stage of stratification: Urban and rural settlements

The purpose of sample stratification is optimization of sample plan and minimization of sample error

Sample allocation within strata is proportional to size of strata – the number of children 0 to 7 years old in the strata

Definition of urban and rural settlements

The division of settlements to urban and rural is administrative. Except for agricultural areas (which are all categorised as rural), administrative division to urban and rural settlements is based on several different criteria: the number of residents of an area, infrastructure, availability/number of schools (primary, secondary, higher), availability/number of healthcare institutions etc. So, this administrative division is not completely arbitrary, but it is also not based on precise enough criteria that would ensure clear definition of urban and rural settlements.

Table 4.1.5 – Description of methodology


Sampling

The sample was created on basis of the 2011. Census and estimates of Ipsos Strategic Marketing for 2013. The sampling procedure was aimed at creating a sample representa-tive for the target population, or for mothers/primary caretakers of children 0 to 7 years old, which is accomplished by defining the sampling units in which interviewers conduct inter-views while observing adequate procedures. The distribution of the selected territorial units by strata corresponds with the structure of target population.

Definition, number and method of selection

– primary (PSU), secondary (SSU) and tertiary (TSU)

sampling units

PSU: Polling station territory

Definition: Polling station territories are defined by the type of settlement and polling station address; average size of one polling place is about 300 households

Sampling type PSU: Probability proportional to sample size (PPS)

Selection method: Lachirie (cumulative)

The number of PSUs in the sampling universe: 8.246

SSU: Households with a child aged from 0 to 7 years

Definition: A household is a group of people who live under the same roof and share food expenditures

Sampling type SSU: Simple random sampling without replacement

Selection method: Systemic sample with random selection of starting point and equal number of steps

The number of SSUs in the sampling universe: 2.5 million

TSU: Respondent

Definition: Household member, parent of a child 0 to 7 years old

The questionnaire will be realized with mothers (or caretakers if mother is not a member of the selected household).

Sample size: 635

The number of sampling points:

With this approach, the number of sampling points equals the number of primary sampling units (PSUs). In a sample of 600 respondents and 8 respondents per

sampling point, the number of sampling points is 75.

Sampling error: Marginal error +/-3.39%

213Appendices

II step – Sample allocation by region and type of settlement

The next step was sample allocation, performed by defining the number of sampling units in each stratum (region*tip). Sampling units in each stratum are selected by taking into ac-count the elements such as size of the population by stratum and defined number of re-spondents in each sampling unit. Although the total sample is 600 respondents, the usual procedure includes planning of a somewhat bigger sample in order to ensure realization of the expected total sample in case some questionnaires are excluded.

If it is considered that total sample is 600 respondents, with the planned ‘surplus’ of ques-tionnaires and defined 8 questionnaires by sampling unit, total sample will be distributed among 76 sampling units. The number of sampling units by stratum is set by proportion, which means that the number of sampling units by stratum is proportional to the share of the stratum population in total population. The number of questionnaires per starting point is predefined in practice and it is usually 8 to 10.

Sample allocation by strata is shown in the Table 4.1.7.

Type of settlementTotal

Urban Other

Region

Vojvodina 89176 54198 143374

Belgrade 111181 22258 133439

West Serbia 23398 29522 52920

Šumadija 54891 40663 95554

East Serbia 23259 16871 40130

South Serbia 38353 30114 68467

Total 340258 193626 533884

Table 4.1.6 – The number of children age 0 to 7 years by region and type of settlement

I step – Assessment of the size of target population

In the first phase, target population size was estimated by region (6 regions) and type of set-tlement (Urban/Other). Given that interviewed were mothers/primary caretakers of children age 0 to 7 years, and since data about the size of this population are not available, sampling was performed on basis of 2011. Census data on the total number of children of this age and on basis of Ipsos Strategic Marketing estimates for 2013. Estimated size of the popula-tion of children age 0 to 7 years is presented in the Table 4.1.6.


1

1

III step – Selection of municipalities

After sample allocation by strata, municipalities are selected and the number of sampling units in each municipality is set. Municipalities are selected using a dedicated software, which enables random selection, taking into account the defined allocation, and proportion-al to their size. This means that, depending on size, or the number of citizens, one or sev-eral sampling units can be selected in one municipality.

IV step – Selection of sampling units

The next step is selection of sampling units. Polling station territories were used as sam-pling units. Sample units are selected using a dedicated software, which enables random selection, taking into account the defined number of sampling units by municipality, and proportional to size, or the number of voters. The starting points, in each sampling unit, are the addresses of polling stations. If the given point has been used as starting over the past 6 months, interviewer is given a starting point two streets above or below the initially given starting point.

Within sampling units, interviewers move by random step, observing the interval 3 in urban areas, or interval 2 in rural areas. This means that interviewers try to get in touch with ade-quate respondent at the door of one in three housing units in urban sampling units and one in two housing units in rural sampling units.

Interviewers move by random step until they complete 8 questionnaires per sampling unit.

Number of children age 0 to 7 years

%Number of sampling

units

Region

VojvodinaUrban 89176 16.7 12

Other 54198 10.2 8

BelgradeUrban 111181 20.8 15

Other 22258 4.2 3

West SerbiaUrban 23398 4.4 3

Other 29522 5.5 5

ŠumadijaUrban 54891 10.3 7

Other 40663 7.6 7

East SerbiaUrban 23259 4.4 3

Other 16871 3.2 3

South SerbiaUrban 38353 7.2 5

Other 30114 5.6 5

Table 4.1.7 – Sample allocation by strata

215Appendices

Face-to-face survey with mothers/primary caretakers of children 0 to 7 years old in Roma settlementsWithin the survey with mothers/primary caretakers of children 0 to 7 years old in Roma set-tlements, 211 mothers/primary caretakers of children of the specified age were interviewed. The 2011. Census data were used for creating of this sample as well. The sampling pro-cedure was aimed at creating a sample representative for the population of Roma settle-ments. Roma settlements were defined as settlements with the share of Roma over 40% 2.

Table 4.1.8. presents the methodological frame for this survey phase

2 According to the official statistics, the share of Roma population in Serbia is 2%

Location: Roma settlements in Serbia

Data collection method: „Face-to-face“ interviewing in respondents’ households

Sample universe:Parents (mothers) of children age 0 to 7 years – household members in Roma settlements or in country areas with high percentage of Roma population;

Statistical documentation used for sample design:

Census 2011.

Sample frame: List of Roma settlements from the Census

Type of sample: Two-stage random representative stratified sample

Sample stratification:

First stage of stratification: Belgrade, Vojvodina, Šumadija, West Serbia, East Serbia and South Serbia

Second stage of stratification: Urban and rural settlements

The purpose of sample stratification is optimization of sample plan and minimization of sample error

Sample allocation within strata is proportional to size of strata – the number of children 0 to 7 years old in the strata

Sample size: 211

Table 4.1.8 – Description of Methodology


Sampling

I step – Assessment of the size of target population

In the first phase, target population size was estimated by region (6 regions) and type of set-tlement (Urban/Other). Given that interviewed were mothers/primary caretakers of children age 0 to 7 years, and since data about the size of this population are not available, sampling was performed on basis of Census data of the total number of Roma.

Estimated size of the population of Roma in Roma settlements is presented in the Table 4.1.9.

II step – Sample allocation by region and type of settlement

The next step was sample allocation, performed by defining the number of sampling units in each stratum (region*tip). Sampling units in each stratum are selected by taking into ac-count the elements such as size of the population by stratum and defined number of re-spondents in each sampling unit. Although the total sample is 200 respondents, the usual procedure includes planning of a somewhat bigger sample in order to ensure realization of the expected total sample in case some questionnaires are excluded.

If it is considered that total sample is 200 respondents, with the planned ‘surplus’ of ques-tionnaires and defined 8 questionnaires by sampling unit, total sample will be distributed among 27 sampling units. The number of sampling units by stratum is set by proportion, which means that the number of sampling units by stratum is proportional to the share of the stratum population in total population.

Sample allocation by strata is shown in the Table 4.1.10.

Type of settlementTotal

Urban Other

Region

Vojvodina 4506 3899 8405

Belgrade 9199 1325 10524

West Serbia 286 3438 3724

Šumadija 2791 669 3460

East Serbia 4239 411 4650

South Serbia 20335 5501 25836

Total 41356 15243 56599

Table 4.1.9 – The number of Roma in Roma settlements by region and type of settlement

217Appendices

III step – Selection of municipality

After sample allocation by strata, municipalities are selected and the number of sampling units in each municipality is set. Only municipalities with Roma settlements were consid-ered, or settlements with the share of Roma in total population over 40%. Municipalities are selected using a dedicated software, which enables random selection, taking into account the defined allocation, and proportional to their size. This means that, depending on size, or the number of citizens, one or several sampling units can be selected in one municipality.

IV step – Selection of sampling units

The next step is selection of sampling units. Census block units are used as sampling units. Sample units are selected using a dedicated software, which enables random selection, taking into account the defined number of sampling units by municipality, and proportional to size, or the total number of Roma.

V step – Selection of starting points

Starting points are selected within each selected sampling unit, by random selection of starting address from the list of addresses. If sampling unit has no list of addresses, the centre of the settlement is taken for the starting address, or the point on equal distance from settlement borders.

The number of Roma in Roma

settlements%

The number of sampling

units

Region

VojvodinaUrban 4506 8.0 2

Other 3899 6.9 2

BelgradeUrban 9199 16.3 4

Other 1325 2.3 1

West SerbiaUrban 286 0.5 0

Other 3438 6.1 2

ŠumadijaUrban 2791 4.9 1

Other 669 1.2 0

East SerbiaUrban 4239 7.5 2

Other 411 0.7 0

South SerbiaUrban 20335 35.9 10

Other 5501 9.7 3

Table 4.1.10 – Sample allocation by stratum


Online research with mothers/primary caretakers of children 0 to 7 years old in general populationOnline research with mothers/primary caretakers on the sample of 200 respondents was aimed at reduction of the influence of non-responses of specific categories of the pop-ulation. In other words, online research covers the categories that are more likely not to respond or that are harder to reach for face-to-face study. Previous studies on general population suggest that non-response rate is higher among younger category members, residents of urban areas and the employed.

Bearing this in mind, the online research covered mothers/primary caretakers of children 0 to 7 years old in urban areas. The sample distribution by age categories and region is pre-sented in Tables 4.1.11. and 4.1.12.

Respondent’s age Region

<30 years 49% Belgrade 36%

30-40 years 51% Vojvodina 27%

Central Serbia 37%

Table 4.1.11 – Sample distribution by age and region

Region N

Belgrade

Total 68

<30 years 24%

30-40 years 73%

<40 years 3%

Vojvodina

Total 50

<30 years 45%

30-40 years 53%

<40 years 2%

Central Serbia

Total 69

<30 years 54%

30-40 years 46%

Table 4.1.12 – Sample distribution by age and region

219Appendices

Post stratification of the sampleWeighting, or post stratification of sample, is the final survey phase aimed at balancing the sample and the population it represents. Implementation of this method is important be-cause it minimizes the differences between the sample and population, so that we can be sure that the data obtained on the sample actually represent the entire population. In this survey, post stratification was implemented two times – on the general population sample (both for „face-to-face“ and for online survey) and on the Roma population sample.

Given that the data about caretakers of children age 0-7 years are not available on the web-site of the Statistical Office, the used alternative sources of data were relevant surveys with reliable methodology – MICS from 2014 and Roma survey from 2011. In addition to these data, we also used the official statistical data about the total number of Roma in Roma set-tlements (where the share of Roma is at least 40%).

Both groups were weighted by the basic demographic parameters – region, type of settle-ment and age category. Education was the additional parameter used. RIM method was applied, which enabled weighting of several variables simultaneously. Weighting enables making conclusions about populations – parents from general population and Roma par-ents, on basis of data collected on samples.


Appendix 7

The structure of management team

Name Position in the project Task Academic

backgroung

Aleksandar Zorić Overall supervision, Team leader

Project coordination and conceptualiyation and quality

control of all research processesPsychologist,

PhD in Statistics

Srđan Bogosavljević

Consultant – Methodology expert Consultancy on methodology design Mathematician,

PhD in Statistics

Jasna Milošević Đorđević

Consultant Key Expert

Survey preparation, data analysis and reporting

Psychologist, PhD in Psychology

Iris Žeželj Consultant Key Expert

Survey preparation, data analysis and reporting

Psychologist, PhD in Psychology

Dragoslav Popović

Consultant Key Expert

Consultancy on whole researh process, data analysis and reporting

Medical Doctor, Senior International

Public Health Consultant

Dunja Anzelm Project managerQualitative Survey moderation,

quantitative survey preparation and coordination, data analysis and reporting

Psychologist, MA in Psychology

Danica Lazić Researcher Moderator of qualitative researches Psychologist

Andrea Kočiš Researcher Moderator of qualitative researches Psychologist, MA in Psychology

Tatjana Jovanov Field work coordinatorSupervision of the process of data collection for quantitative

phase of the research

An engineer in the process of completing

the studies

Tatjana Vuković Head of scripting department

Data entry, coding, writing scripts for data entry, managing data

processing sector and data clening, logic control, formatting data basis and applying standarad procedures

for keeping privacy of the data

Sociologist - in the process of completing

the studies

Sanja ŠanjevićHead of data processing department

Coordination of data processing, data processing and analysis – data tabulation and reporting

Informatics engineer

221Appendices

Appendix 8

Full narrative report on in-depth interviews

Evaluation of the legislative framework on immunization and the success of its implementation in practice

Key informants and medical workers generally assess positively the current legislative framework concerning immunization. According to them, the law clearly defines the pur-pose of immunization, as well as the fact that immunization is a process of general social interest. However, both groups of respondents point out that there are problems in imple-mentation of this law, as well as the fact that these problems have different manifestations in practice.

The key informants primarily think that significant problem at the moment is the lack of sep-arate Rulebook on immunization, which, according to them, significantly limits the struc-ture and systematization of the work of all health institutions involved in the process of im-munization. As they state, the reasons for this do not lie in the fact that there is no will of the competent institutions to adopt this Rulebook, but the fact that its adoption is limited by the administrative procedures that make this process a long and slow.

„ The law is clearly defined, but we have a problem with the Rulebook and program which the experts are preparing, that still hasn’t been adopted.“

– Key informant

On the other hand, the statutory provision of compulsory vaccination provokes contrary views of key informants and medical workers. For key informants, clear legal definition of the type and level of penalties for those parents who refuse to vaccinate their child is cer-tainly a justified sanction, which in the long run can lead to an increase in the coverage of the vaccination. However, medical workers state that the mandatory vaccination for them is a sword with two blades. Although this removes any responsibility from medical workers for possible side effects or contraindications that can be caused by vaccination, they report that they have encountered negative reactions of parents during their practice, as well as the fact that the position of someone who places the vaccine as a mandatory requirement, is not comfortable for them. Revolted by their negative experiences, some of the interviewed medical workers go and a step further, and state that vaccination should not be mandatory.

„I think that there would be less negative comments if it were not mandatory.“ – Paediatric nurse

„In general, parents have the right to refuse to vaccinate their child. They are obliged to sign that, and we are not responsible any more.“ – Visiting nurse

„There is not a legal provision that the child need not be vaccinated if the parents do not want it. Maybe such provision should be included in the law.“

– Paediatrician


„The paediatricians are grasping the easier solution, because the parents are threatening them, so it is easier to agree with parents’ wishes.“ – Key informant

The problems reported by key informants and medical workers regarding the criminal pro-cess for those who refuse to vaccinate their children can be roughly divided into two cate-gories - problems with the behaviour of medical workers themselves in direct contact with the parents who are in dilemma or do not want to vaccinate their children, as well as problems related to the real sanctioning of medical workers and parents who, by their behaviour, influence the fact that the child does not receive vaccines.

„Paediatricians expect not have to think about anything. According to legislation, we have compulsory immunization and immunisation which is

recommended. We currently have a situation where paediatricians themselves decide whether to perform immunization and, most of all, because of fear,

parents postpone vaccination with MMR vaccine from fear of autism. They try not to vaccinate the child at the age of 12 to 15 months, but as late as possible.

This fear of parents is transferred to doctors and because of this, the child receives vaccine as late as possible. They do not accept the new science, but

they believe that the MMR vaccine is not good.“ – Key informant

„If my opinion was that the child need not be vaccinated, and if there were no consequences for the child, we simply do not vaccinate the child, and that’s it.

There were no consequences either for me or for the child.“ – Paediatrician

„Law cannot be flexible when it comes to vaccination. Flexibility should be reduced even in terms of contraindications... For example, there must not be allowed to postpone MMR vaccination after the age of 2 years on the basis of

false contraindications, because some paediatricians are frightened to vaccinate children early in fear of autism.“ – Key informant

Therefore, there is a distrust in key informants, but also in medical workers regarding the processing of punitive measures for parents who refuse to vaccinate their child. In their opinion, the work of the inspections of competent institutions is not at an enviable lev-el, and it is important to establish better quality control mechanisms for this problem. Also, some medical workers state that they have not personally reported to authorities the fam-ilies that have not vaccinated their child, due to the previously stated fact that they do not support the obligation of vaccination, and consider it to be a decision that the parent has to make independently without any coercion. Other medical workers report that during their practice they had only a few cases when they informed the competent authorities that the parents refused to vaccinate their children but did not receive any feedback from them about the outcome.

„The law has been adopted, and punitive measures are not implemented.“ - Visiting nurse

223Appendices

„There is a penalty for non-implementation of immunization both for parents and for the doctor. But there is also a question of whether any inspection will come

and check situation and implement a penalty.“ – Key informant

„If parents do not want to vaccinate their child, it is paediatrician’s duty to report it to sanitary inspection. Paediatrician doesn’t do it because he/she thinks that next time he/she will persuade the parents, and inspection doesn’t act because

they don’t want to “stir up the water”. Number of cases where parents were reported is very small.“ – Key informant

Finally, according to some key informants, primarily the ones who are not on the highest level of immunization chain, significant problem in actual law is the fact that it doesn’t stipulate compensation to parents of children who have significant side effects af-ter vaccination. According to their opinion, this would be an important step which would not only make possible better attitude of general public towards immunization process, but children who fall ill from some disease in rare cases would receive the needed financial aid.

„There must be a compensation fund for mandatory vaccination. This means that, if some unwanted reaction occurs, the state must provide compensation. Because, if someone is forced to vaccinate a child, and this

child is one in a million who will suffer from side effects, the state must compensate the parents.“

– Key informant

„We must have the principle similar to one in America where they evaluate whether two phenomena are associated, and if they cannot exclude connection, they give compensation. There must be a fund for such cases.“ – Key informant

Strong and weak links in the process of immunization

There is a difference in the attitudes of key informants and medical workers regarding which link is the weakest and the strongest in the process of immunization in Serbia. Namely, key informants primarily accentuate the importance of legislative framework, competent min-istry, accessibility and availability of vaccine.

„I see an individual as the strongest link, people like me, who push this story.“ – Key informant

„Accessibility of vaccine is the strongest link.“ – Key informant

„The strongest link is expertise, knowledge, education.“ – Key informant


Representatives of healthcare sector think that the strongest links at this moment are efforts to increase general awareness of parents about importance of vaccination, which is particularly important in case of Roma families, that is, medical workers them-selves who contribute to vaccination compliance through direct contacts with parents. They think that paediatrician is the person who should promote importance of vaccines and, in personal contact with parents, actively inform them about its importance, and eventually, if it is necessary, persuade parents to vaccinate their children. They particularly accentuate the importance of Roma mediators who, according to majority of respondents, have sig-nificantly increased the vaccination coverage in Roma population.

„In my opinion, the strongest link in our work is paediatrician. This is the person with whom parents establish the first contact when they bring their

child to health check. The paediatrician takes care about the child until the age of 7 years, and his/her opinion is very important as well as his/her advices.“

– Paediatrician

„I always consider it as a great success when I visit the Roma settlement and mother tells me that she has a scheduled term for vaccination. On the other

hand, awareness of parents has been upgraded. I had a case when the child got sick. My fear was that the others would get frightened. But, mother was

aware that this maybe wasn’t because of vaccines. Doctor in hospital confirmed it. Due to persistent work with them it didn’t happen.“ – Female Roma mediator

When it comes to the weakest chains, the key informants and medical workers largely agree in their answers. They primarily point out that media have a negative impact, particularly electronic media, due to significant presence of false and unproven in-formation about negative impact of vaccines on child’s health. To a lesser extent they mention general decrease of citizens’ confidence in health system due to its long stand-ing unenviable position caused by previous events with shortage of vaccines, and due to poor general knowledge about vaccination.

„Education of parents, citizens is the weakest point.“ – Female health sector representative

„Decrease of confidence in health institutions on one hand, and poor awareness of parents on the other hand, are the weakest links. They rather trust someone

on Internet than their paediatrician.“ – Key informant

Assessment of vaccine availability

In the assessment of availability of vaccines opinions of key informants and medical workers are also divided. According to key informants and medical workers previous problems re-garding accessibility and availability of vaccines were caused by insufficient coordination of work among competent institutions and failure to recognize the need for reserves. According to both sides, although the current situation is significantly better compared to previous period, health system in Serbia still doesn’t show sufficient responsiveness

225Appendices

towards the needs for vaccine stocks, in particular for the recommended coverage of the vaccines or for the quantities corresponding to the required compulsory reserves. However, this opinion doesn’t exist among representatives of higher instances who believe that the current availability of vaccines and their availability is at the required level.

„I can say that supply stabilized last year, but shortage of vaccines had been by far more important problem in earlier years, than were some medical reasons

such as hepatitis B, that is, the imported vaccines.“ – Key informant

„Since the year 2005 we’ve had problems with acquisition of vaccines, that is, insufficient quantity of vaccines, where vaccines are observed as a market

category. It is absolutely wrong not to recognize the phenomenon of compulsory reserves, where number of children cannot be equal with number of vaccines,

but it must be increased by compulsory reserve.“ – Key informant

„The offer for compulsory program of immunisation is good, while recommended program of immunisation is not“ – Key informant

„ They always say that tenders are disputable. The state makes a delayed order, these orders are made on the level of state, these are big numbers, so

Pasteur Institute, or some other foreign producers, because we do not have our producer any more, can’t produce such large number of vaccines in such a

short time period.“ – Paediatrician

„You asked me about the purchase of vaccine, this is a weak link. I think that this situation is such from the time when they introduced tenders for acquisition

of goods. Persons who do it do not take it seriously enough, they don’t apply in time and they do not apply for sufficient quantity, so some 5 years back we

have always been short of vaccines. This is also something that provokes distrust among parents. I don’t want to say that there is no continuity, but that it

is inconsistent.“ – Paediatrician

Medical workers state that problems with availability of vaccines in the previous peri-od had a negative impact on confidence of the parents. Some paediatricians state that availability of vaccines could be tagged as the weakest link in the system of immunisation in Serbia, because shortage of some vaccine is not a rare occurrence. In contrast to that, some paediatricians claim that situation with vaccines is currently good, and they often compare it with some earlier periods when serious shortages were recorded, for example, the period when Serbia was under sanctions.

I can’t say 100% that everything is as it should be, occasionally we have shortages. Sometimes it happens that we do not have the delivery for a month

or two. Concretely now we do not have polio vaccine, and preparation of children for the first grade is underway. So I can say that the

supply is not too good.“ – Paediatric nurse


„It happened several times that the child was due to receive vaccine and Health Centre didn’t have it.“ – Female Roma mediator

Experiences of health workers indicate that problems with inaccessibility of vaccines have somewhat impaired the trust of parents, but, according to them, efforts are being made to prevent it. Paediatric nurses and other administrative staff timely inform parents that vac-cination is postponed for the period of delayed delivery, so parents come for vaccination on these postponed terms. Paediatric workers also have experiences that da parents have a free choice to buy vaccine in pharmacy, however, majority of them advise the parents not to do it because it is usually in a short period of time when the vaccines will be available. On the other hand, a certain number of interviewed medical workers do not have a positive at-titude towards these vaccines, because the quality of their storage is questionable, so this is one more reason due to which parents are advised to buy vaccines.

„Everywhere in the world the vaccines are mandatory and they are received only in health institutions, while in our country they can be bought in pharmacies without prescription, without knowing the effect or way to be administered, this

is terrifying.“ – Paediatrician

„We always advise parents to wait until the vaccines arrive, why would they give money if the kids have the right to free vaccines.“ – Visiting nurse

„From time to time we have shortahe of some vaccine, for a week or two, but in the meantime parents call us and we inform them when the vaccines will be

available.“ – Paediatric nurse

„In one case the vaccine bought in the pharmacy was not good, parents bought the vaccine, my colleague saw that the solution was not clear, it was turbid,

which is not characteristic for that vaccine, so we returned it to pharmacy and they replaced it with another one free of charge.„ – Paediatric nurse

According to some key informants important problem is the status of Torlak. They think that we should better use the fact that Torlak is a national company, so it is necessary to make the necessary steps and design strategies that would maximally use the capacities and possibilities of Torlak, with minimisation of imports of foreign vaccines. Some of the key informants state that the problem of Torlak is competence of staff, obsolete production equipment and politicization of its operation.

„Unfortunately shortage of vaccines had a negative impact. This is an important problem, but this also shows the attitude and seriousness of the state towards

these things. As regards Torlak, it is very important that we have our own company, producer of vaccines, because not all the countries have such institution. For 25 years we put political party members at the head of the

company, not experts, and this is a problem. So they just kept sucking money, tenders were faked, no one took care about it.“ – Key informant

227Appendices

„Torlak will not be able to produce the bulk of vaccines from mandatory production programme in the long run...“ – Key informant

Vaccine storage, availability of accompanying equipment

All medical workers state that there exists a strict mechanism or rules which relate to stor-age and preservation of vaccines, so noncompliance with these rules is forbidden by the law and impossible. They also state that these regulations also cover the proce-dures for special occasions, for example, in case of power failure in health centre, which strongly facilitates the work of health institutions in such conditions. Paediatrician from one health centre also states that there was special training for health workers where they were educated in terms of storage of equipment for vaccination, and there was a condition that only health workers with such training could work with vaccines.

„In both shifts there is only one nurse who is in charge of vaccination. Not all nurses are allowed to do that, but only the nurses who were educated for

proper administration of vaccines, she takes care about cold chain and all other things concerning vaccination.“ – Paediatrician

„We, in health centre store the vaccines according to very strict rules, and we have defined rules as to how to act in case of power failure or some defects

on refrigerators, there is a complete procedure which relates to vaccines, and I think that it is perfect.“ - Paediatrician

Evaluation of immunisation calendar

Immunisation calendar is perceived as a document which is primarily legally determined, and both medical workers and parents must respect it. Majority of the interviewed medi-cal workers perceive the vaccination calendar as the result of work of epidemiologists who know the recommended timeline for immunization, so they do not have dilemmas wheth-er the current immunization calendar is adequate or not. However, some medical workers point out that it would be desirable to move the prescribed time for MMR vaccination, again because of the increasing pressure of parents to postpone this vaccine until the child starts speaking. In their opinion, this would reduce the number of unpleasant experiences which currently happen, while parents would be more ready to accept this vaccine, which would generate a more positive attitude towards this vaccine in time.

„The calendar is good, provided that we have the power to postpone it and give vaccine at the age of 12 months, I can give the vaccine at the age of one

month, six months, it depends on assessment of the child.“ – Paediatrician

„We would like to ask whether it is possible to give the notorious MMR vaccine at the age of 24 months instead of 12 months.“ - Paediatrician


Assessment of the consent form for vaccination / non-vaccination

According to a number of key informants, written consent forms for mandatory vaccination are unnecessary. Dominantly, there is a negative attitude towards them, because they seem to provoke doubts and distrust towards vaccines among parents. On the other hand, written consent forms for recommended vaccines are evaluated positively, and their use is considered justified.

„They (forms) make more confusion. This causes suspicion among the parents and I think that they are not useful. Parents believe that, by putting their

signature on consent form, they take all responsibility for all side effects.“ – Key informant

„There is no sense in it since the vaccination is mandatory. There is another form which is signed by the parents who refuse vaccination, and this goes in

further procedure, to inspection bodies.“ – Key informants

On the other hand, it seems that medical workers have an ambivalent attitude towards mandatory forms for refusing vaccination. The biggest objection of some of them is that these forms are not standardized and that healthcare institutions must independently cre-ate their content. This is assessed as a big problem; paediatricians state that precise for-mulation is extremely important because of self-protection of health institutions. On the oth-er hand, some of the paediatricians again point to different interpretations of procedures in cases when vaccination is refused. For example, some paediatricians ask parents to sign the non-vaccination form the first time when they refuse vaccination, while other doctors try to negotiate with them and allow them to think it twice before giving them the form to sign. On the other hand, Roma mediators state that they are not aware of these forms, and that they have never seen them in their practice.

„Parents are a bit insecure when they have to sign a form. They always wonder why, there is always some doubt. I think that these forms are pretty senseless.“

– Paediatric nurse

„First of all you don’t have a form on national level, but they are made by various insufficiently trained jurists...We do not have a standardized form on national level, although every word in this form is important.“ – Paediatrician

229Appendices

Assessment of institutions involved in the process of immunization and their mutual coordination

Perception of institutions

The interviewed respondents from all institutions are satisfied with the efficiency of their work – both the higher instances in the chain of immunization, and representatives of Institute for Public Health in various parts of Serbia, the medical workers, and finally, representatives of NGO sector who upgrade the process of immunisation in Serbia by informal ways.

„We cover three municipalities and there is one other Institute which was established on the territory of other district. I am satisfied. Within the law we perform our activities without any limitation and pressures.“ – Key informant

Nevertheless, they report about current disadvantages, both inside the institutions and in cooperation with other institutions. Some key informants, but also medical workers often criticize higher instances because of insufficient engagement in media and poor re-sponse to increasing anti-vaccination association. According to them, positive commu-nication of representatives of Health Ministry and Institute for Public Health (Batut) usually doesn’t exist, which directly leaves a significant space to representatives of anti-vacci-nation movement to impact their opinion. On the other hand, representatives of higher instances do not perceive these problems, and they think that there is no need for change in their work with respect to this.

„In any case, this feedback would have to be a bit more lively. Especially from primary care institutions and public health institutes upwards.“ – Key informant

The next problem which is mentioned is generally excessive workload of health institu-tions. According to key informants and medical workers, there is a significant understaffing problem within health institutions which considerably limits the domain of work – it reduces it to intervention not prevention. Namely, medical workers point out that, during one work-ing day, they do not have time to devote adequately to each patient. Due to such situation, patients are often given scarce information, which is a significant problem for parents who do not have a clearly defined decision whether to vaccinate their child.

„It happens that health workers are very tired, they work with less enthusiasm, and they have less time to devote to patients, which is unacceptable.“

– Paediatrician

„The work in primary health protection should be changed. During our working hours we should work more on prevention than intervention, because money

invested in prevention returns multiple times. If you educate parents well about what they should do in certain situations, if you persuade more of them to

vaccinate their child, you will have less ill children and money spend on treating these patients will be lesser.“ - Paediatrician


Key informants from health system think that they have a limited responsibility in the process of decision making about vaccination. They perceive their institutions rather as the instances which implement the decisions, and they perceive higher instances on na-tional level as responsible for decision making. Medical workers neither wish nor they have motivation to be more involved in the process of decision making, primarily because, at this moment, organisation of their work doesn’t allow that. Finally, among certain representa-tives of health sector there is a conviction that their suggestions would not be taken into ac-count, so the idea of decision making is generally strange and far from them.

„If we think that something can contribute to vaccination coverage, we tell Health Ministry about that. At least they listen to us.“ –Female Roma mediator

„Well, we do not have too much influence...you simply can’t influence something that’s above you.“ – Paediatric nurse

Perception of coordination of institutions and cooperation

Among key informants and health workers there is a conviction that there is a sufficient coordination among all relevant actors in the process of immunisation, which, in the pre-vious period, resulted in the fact that full potential of immunisation was not used in Serbia. Most frequently mentioned example is that there is no systematic planning of acquisition of vac-cines, which occasionally results in shortages and even spoilage of acquired vaccines.

„ A solid link must exist and it must be timed and well-coordinated so that eventually all vaccines are available at each vaccine point. It happened in

the past years when antipneumococcal vaccines arrived as a donation, that part of those vaccines had to be returned. That would be an example of our

disorganization.“ – Key informant

On the other hand, actual communication among institutions is evaluated in positive way. Nevertheless, it is registered through deeper analyses that there are clearly defined circles of communication, within which there are defined directions of communication, and there are no significant deviations from that – namely, health centres usually communicate with lo-cal institutes for public health, the institutes communicate with Institute for Public Health, while the Institute for Public Health usually communicates with Health Ministry and Republic Health Fund. Representatives of Institute for Public Health and paediatricians usually have communication with regional coordinator due to the nature of their job, and they are usually satisfied with it. Paediatrician from Novi Sad also states that there exists communication between health centres and Provincial Health Institute, and that this commu-nication is on satisfactory level. On the other hand, key informants from informal sectors cov-ered by this study particularly criticise communication with Health Ministry which often shows signs of insufficient responsiveness to current problems of immunization. This cooperation is hampered by limited budget of Health Ministry - which is why the steps recommended in order to improve the immunisation coverage are not implemented.

„There isn’t a single health institution with which we do not have adequate cooperation in the country at the moment. The only institution with which we

have no cooperation is Republic Fund for Health Insurance. „ – Key informant

231Appendices

„I am satisfied with the work of institutions in the network of the Institute. I am not satisfied with those who ignore the recommendations of the network. When I say ignore, I mean that they constantly ask for list of vaccines which need to be purchased, and they do not accept anything additional. If we mention some problem that needs to be solved, they absolutely ignore it, they just blindly stick

with the vaccine list which have to be bought, without any additions.“ – Key informant

„The paediatricians are the most important in this system, cooperation is excellent, the colleagues consider us as someone who can help them solve

certain problems, not someone who controls them and reports on them. So, we have excellent cooperation in this everyday sense.“ – Key informant

Representatives of health sector also point out that there is a harmonious and success-ful cooperation with local institutes for public health, and this communication usually evolves through paediatricians. It is claimed that this communication evolves both on regular level, when vaccination coverage is reported, but also when concrete prob-lems occur, such as situations when parents do not bring children to vaccination.

„We have a good cooperation with city coordinator. Last time when we were in contact was a month ago.“ – Paediatrician

Separate segment of health sector representatives covered by this survey are Roma me-diators. They have various initial experiences in cooperation with health centres. While some of them state that they were faced with positive attitude of medical workers in health centres who recognised and supported the role of mediators, other Roma mediators state that they were faced with distrust of medical workers and that confidence and cooperation came after a long period of time. Actual cooperation is evaluated very positively; Roma me-diators are specified as important source of support to visiting nurses and paediatric nurses whom they address if they face some problem during their fieldwork. One problem which they have now are migrations of Roma population, which hampers evidence on vaccination. The Roma mediators usually solve these problems in communication with visiting nurses and paediatricians.

„Barriers are the link between Roma population and institutions. The beginning of work was difficult, until they accepted us – local government, health centres. We had extensive training, but we do not have medical school. This path was

difficult. But I quickly established contact with all these instances. Visiting nurse introduced me to everyone in health centre. Then I went to local government.“

– Female Roma mediator

„Cooperation is excellent, both we try to accommodate their demands and vice versa. There are women who have not visited a gynaecologist for 20 years. I

took all of them, in groups of 3 to 4 women. The gynaecologists saw all of them.“ – Female Roma mediator


„One big problem is going abroad. They start vaccines and they leave. Sometimes they come back, sometimes they don’t. So, we lose the track. We check all returnees, and every child who comes from abroad is vaccinated.“

– Female Roma mediator

One of the interviewed female health sector representative, female Roma mediator, claims that, at the beginning of work in Roma communities, she faced various problems caused by fear and lack of information among Roma population. Besides that, Roma population expressed significant resistance to vaccination. At the beginning of program of cooperation with Roma mediators majority of them didn’t have health insurance, health re-cord cars, so the step which preceded immunisation was integration of Roma population in health system.

„The Roma were conned by many. They took their ID cards, promised them who knows what, and these promises were not fulfilled. When we started

working it was difficult to enter the families.“ – Female Roma mediator

„It was difficult at the beginning. Parents (Roma) did not know the purpose of vaccination, because this is done periodically, their awareness was on a very

low level. A number of them had no documents, they are not registered in birth register, and this causes problems. The first thing I did was to try to raise their awareness through workshops and conversation with parents. In time things

became better and better.“ – Female health sector representative

In time, through workshops, regular visits of Roma communities and persistent work with them, general attitude of Roma towards immunization became significantly more positive. Roma mediators think that they had an important role in this process, and that their pa-tience, support and friendly attitude was of key importance for improving the situation.

„If you have success in one, two or three Roma families this is heard in Roma settlement. You don’t have to go door to door any more, they come to you.

When they saw that we obtained vaccination free of charge, they accepted us. When we started working 90% of children were not vaccinated, but it is quite a

different picture today.“ – Roma mediator

„Our role is great, because there are people who think that if they skip vaccine they cannot do anything anymore, they are not informed, we inform them about

all that, that they have to vaccinate their children.“ – Roma mediator

Roma mediators name as a positive change the fact that, in the past, vaccination of Roma children was done collectively in Roma communities, while these days it is regulated through organised or individual visits to health centres, which additionally points to adequate integration of Roma population in the health system.

233Appendices

Communication among stakeholders

Evaluation of communication between medical workers and parents

Talking about communication with parents, medical workers state that they often face parents who have doubts, and some of them initially have negative attitude towards immunization. According to medical workers, but also informed key informants, medical workers, particularly paediatricians, are currently overburdened with work, which con-siderably affects their commitment in personal contact with parents, including pro-vision of relevant information about vaccination. Majority of them try to give parents all information about vaccination (including advantages of vaccination, risks and counterindi-cations). They express positive attitude towards vaccination, but they always allow parents to make personal decision whether they will or will not vaccinate their children. The com-mon arguments which medical workers use in communication with parents are personal ex-periences, that is, the fact that they vaccinated their own children. They also communicate the importance of vaccines in the sense of disease prevention. However, respondents from health sector also show a kind of helplessness, which is reflected in the fact that they justi-fy their performance with already mentioned excuses – significant pressure of parents who are under the influence of media about harmfulness of vaccines. At the same time, they don’t want to invest themselves on this task – some of them do not feel competent enough to answer all questions of parents, some fear from parents’ reactions if they try to persuade them, while others think that vaccination is an individual decision of each parent, so the doc-tors are not obliged to enter the zone of persuasion.

„I specify positive and negative sides, the decision is on them, these children are theirs. I am always in favour of each child being vaccinated. I always show

my attitude.“ – Paediatrician

„I always respect the opinion of parents and I think that their decision regarding vaccination should be respected. I cannot make this decision instead of them,

these are difficult decisions. I also respect the decision of parents who are against vaccination. Our task is to tell them facts, arguments. They should

consider it and make a decision, they can see that things are not the way they are presented in media.“ - Paediatrician

„As regards communication with parents, it is partially OK, hey accept recommendations of paediatricians. The only problem is MMR vaccine, there is a widespread hearsay that they cause autism, parents are informed from who knows where, and some of them decide to refuse vaccination.“ – Visiting nurse

„We tell the parents that the child can have serious consequences, that the ideas that they have are wrong, and that it is better to vaccinate the child. But they generally have the right to refuse vaccination. They just have to sign the

non-vaccination form, and we are on the safe side. „ – Paediatric nurse


Medical workers also say that they have seen, but rarely, situations when parents asked for additional information about vaccines. They mainly wanted information about the country of origin of vaccines, adverse effects and shelf life. Roma mediators don’t report of such experiences, but they say that parents have asked them whether MMR vaccine triggered autism. They overcame these situations successfully, because they were trained how to re-act in such situations.

„They asked for the serial number of vaccines, information about the country of origin and other information. But not often.“ – Paediatrician

„MMR vaccine is connected with autism. This vaccine is a huge problem, others are not.“ – Female Roma mediator


Communication between institutions and general public is perceived very negative-ly. Our respondents, both key informants and medical workers couldn’t specify any insti-tution relevant for communication with general public, because they believe that this is the activity in which everyone should be engaged, from primary healthcare to higher instances. In their opinion, this is especially important for raising general awareness, because of general ignorance, mistrust in the health system, but also strengthening of the an-tivaccination movement and general availability of false information on the internet.

Moreover, representatives of informal sectors underline that this communication needs to be more transparent and adapted to common people – with minimum usage of medical terms, and with clear specifying of advantages and disadvantages of compulsory vaccination.

„Many institutions don’t educate people, and they avoid everything that smells of confrontation.“ – Key informant

„There is no proactive influence on the population, only tabloid.“ – Key informant

„This is a matter of skilled marketing and not of personal attitudes. I’m thinking of the ways some attitudes, ideas and opinions are launched in public by

representatives of the Ministry and Batut. It is not enough to be informed, but you need to know how to communicate the message, through which media etc.“

– Key informant

„We are all responsible. The Ministry of Health needs to coordinate this. Then Public Health Institutes, and health centres, primary first of all. Professional

associations too. All members of the system need to be engaged in the process of spreading information and persuading the public in the

usefulness of vaccines.“ – Key informant

235Appendices

Medical workers believe that informing parents must be developed. They consider high-er instances responsible for poor awareness, while personal responsibility for providing information is limited by insufficient capacities for preventive work. In addition, some medical workers believe that there is a need to create special campaigns and strategies for informing parents, since this is the initial step necessary to conduct the campaign aimed at changing the awareness of the entire population.

„The Ministry of Health is particularly responsible for this communication and this needs more work.“ – Paediatrician

„The public is overwhelmed with negative opinion that children shouldn’t receive vaccines, while the other side is silent. Everyone should be engaged in

spreading information.“ – Visiting nurse

In general, internet is perceived as the main source and the main cause for insuffi-cient or inadequate knowledge. In addition, citizens don’t trust the health system much, which is generally the problem with the entire health system, and not only with immunization.

„Some phenomena destroy the reputation and trust. I’m referring to the behaviour of medical workers who are being blamed for their mistakes more than other professions are. Healthcare and education have been pilloried for some time now and labelling is allowed. Perhaps citizens’ great expectations

are to blame for this dissatisfaction.“ – Key informant

„I think it’s bad. There is some progress, but people have lost confidence in healthcare as a system. We had situations which ruined everything, such as the avian influenza. Vaccines that were charged and then for free. This all destroys

trust in paediatricians. Not only in terms of vaccination, but everything.“ – Key informant

“Parents are mainly under the influence of the media. They bring most of the confusion. The exception are parents with their own initiative, who seek

professional literature. But there are not many of them. Parents should get most information about vaccines from paediatricians.” – Key informant

Key informants and medical workers say that they often meet parents who have read on the internet that vaccine is harmful. The number of these parents keeps growing, they are sus-picious because of such information, while there are fewer parents to whom paediatrician, a professional, is the main source of information. The strongest belief currently present in general population is that MMR vaccine is connected with autism, while some also believe that vaccines are harmful because of their composition and that there is a global conspiracy of pharmaceutical companies, which produce vaccines for their own end only. This information mainly comes from the media, and the question is why there is no media control in this regard.


„The first excuse is always the connection between MMR vaccine and autism. This comes from parents, but also from doctors who keep spreading this. And

another thing is seeing this as a conspiracy, that pharmaceutical industry is making profit on vaccines.“ – Key informant

„Those who come to us have read many articles and they consider it validated. They are suspicious about any arguments that you mention. Another problem is that some people see this as a global conspiracy, so they say that Torlak is not our company anymore, but that some world mafia took it and now they are selling us what they want. They suspect the quality of imported vaccines, and

also quality of our control.“ – Key informant

„Some believe that vaccines contain poisons, mercury, aluminium... The media have launched lots of negative information about this... „ – Key informant

„A mistaken belief is widespread currently that there is no need for vaccination against some diseases that are considered light, while vaccine can have a

whole range of adverse effects. Before immunization, these diseases were not light. This is the key ignorance and a barrier.“ – Key informant

„They have no arguments, but only their stories. They are informed either partly or wrongly, and their strongest argument is that we don’t know what they put in

the vaccines, a conspiracy.“ - Paediatrician

The public is also coloured by the growing antivaccination movements. Quite expectedly, all respondents have extremely negative opinion about them, especially of those originating from the medical field. Individuals are most visible in public, while not a lot is known about organised associations. Respondents in Belgrade are most familiar with all these. According to many respondents, the arguments that supporters of this idea share are absolutely unfounded, and the media should bear some responsibility for their sensationalistic appearance in public. Confronting them in public is evaluated very neg-atively by majority of key informants, who believe that this gives them attention and legitima-cy. Parents who are perceived as most susceptible to ideas promoted by opponents of vaccination are parents of medically vulnerable children (mainly autistic).

„Doctor Velkov is most famous. Her activity is very dangerous and she misleads parents. The state should have reacted a lot more quickly in this case,

but it failed.“ – Key informant

„I don’t know why they are allowed to have public appearances.“ – Key informant

237Appendices

„None of these are scientific arguments. These are usually fictional information about disasters, epidemics, catastrophic consequences, adverse effects, which

leave a substantial trace on some parts of the population.“ – Key informant

„When we had open confrontations, conflicts and disputes with opponents of vaccination, our coverage was dropping, so this may mean that our

communication was wrong, after each duel they claimed that we won, but we actually gave validity to them, to their attitudes, which parents obviously trusted

more, so coverage kept decreasing.“ – Key informant

Unlike key informants, medical workers expect the antivaccination attitudes to be direct-ly opposed by the professional public, which should be proactive instead of reactive.

„Healthcare is always defending itself on TV. It should be promoted in the media. The Ministry needs to realise that the people have to regain trust in their

doctors.“ – Paediatrician

„When a disease appears, some doctors appear in the media and that’s it. And then they talk about immunization. This should be done more frequently, not

when a problem occurs.“ - Paediatrician

According to key informants and medical workers, there is a need for communication strategy with the public, long-term and continuous. For instance, distribution of promo-tional materials, such as brochures, leaflets etc. with calendar of compulsory immunization, but also with explanation about the applied vaccines.

“We should have more documentaries, information where and how these vaccines are produced, what they contain, the media need to present the real situation because people don’t take part in public discussions.“ - Paediatrician

They also suggest educational workshops for parents, especially for future parents, so that they can be prepared for parenthood, and informed about vaccination. Documentaries are considered very useful, since they can present the diseases targeted by compulsory vac-cines, as well as consequences of epidemics. Some experienced medical workers believe that not only the public, but also their younger colleagues don’t quite understand which dis-eases are targeted by vaccines and what kind of complications they may provoke, since they haven’t seen them in practice.

„I think the people will only come to their senses after an epidemic, which will leave consequences unfortunately.“ – Key informants

„We need to be more visible, but this is not just a matter of our will or wish, but of how willing the media are to accept us.“ – Key informant


„The problem is that doctors have never seen some of the diseases that have been eradicated owing to vaccination, such as diphtheria or children’s paralysis,

so doctors and parents become less cautious.“ – Key informant

„We can educate parents when they come to us. We can help them with advice, recommendations and information.“ – Paediatrician

„They need to be explained the benefits of immunization during pregnancy. Paediatricians play an important role in this, they mustn’t get tired of

communicating useful information about immunization.“- Key informant

Training courses for amateur and professional publicAttending different courses and their organization, especially by informal societies, is common. These courses are perceived as beneficial, empirically supported, but intend-ed for medical workers first of all, and not the general public. Key informants from the state sector state that it is more difficult to organise training for general population, that there is a problem of parents’ response, but that there are plans for conducting such activi-ties throughout Serbia in the future.

„We have continuous and regular education of medical workers. We have more than 80 points in the field that we visit each year. We also have online courses

about vaccination.“ – Key informant

„The activities of the association of paediatricians have been addressing doctors more. Although we have had some activities targeting general public

too. These are media appearances. It is done regionally, each place has its own TV and radio now. Our doctors do this often.“ – Key informant

„When a new vaccine is introduced, accreditation is the first step, followed by training of medical workers. This is a bit difficult in general population because of organisation. We are doing our best, we are making plans, we are having

some focus groups with parents now. It’s not simple because of organisation.“ – Key informant

„We have continuous medical education. I take part in public discussions, we have promotions, meetings. We were engaged by UNICEF for the Roma

population program. There should be a lot more of this.“ – Key informant

239Appendices

„We have organised many public meetings. But we took no step beyond. The Ministry wasn’t interested in making this closer to parents, those who are

scared and who need support and education. So that they don’t have dilemmas about vaccination. Not many steps are taken to get closer to that population.“

– Key informant

Medical workers, primarily paediatricians, say that they have attended courses about immuni-zation, as well as workshops, round tables and lectures of foreign experts. They consider these sessions beneficial, but they say that these courses also reveal that other medical representa-tives have their doubts too, which illustrates how strong this influence is at the moment.

„Paediatric section of the Serbian Medical Association is very active and we have many seminars, courses and congresses.“ – Paediatrician

„We have many lectures because this is necessary for validating our work licence. Immunization was the topic at the beginning of the year.“

– Paediatric nurse

„Yes, seminars are organised often to keep us informed and to provide certificates that we need to have.“ – Paediatrician

Roma mediators also underline the significance of training courses and lectures they at-tended, as well as that this helped them largely during fieldwork. However, this education takes place apart from the rest of the healthcare sector.

„I had seminars, education, doctors were the lecturers, we had several about vaccination.“ - Female Roma mediator

„We have training sessions often and all mediators from Serbia attend.“ – Female Roma mediator

Comparison with EU countriesIf we compare the practices in Serbia and the EU, we see that majority of respondents agree that our legal frame is largely aligned with the general EU standards. The obvious differences refer to communication with parents and improving of general awareness. The examples of good practices are countries in which each parent has a vaccination calendar with clearly defined timeframe for vaccines and the reasons why they should be received. As for the countries where vaccination is not compulsory, there is no general at-titude of the interviewed regarding this issue. Namely, some believe that, even if it is not publicly communicated that vaccination is compulsory, the legal frame in these coun-tries regulates this in such a way that children can’t ne integrated in the social system without vaccination. On the other hand, medical workers seem to be less informed about the system of immunization in other countries, they are unsure whether vaccination is compul-sory and they are not familiar with the consequences of avoiding vaccination.


„The success of immunization is better since the 90s, even then we had the leading coverage in Europe. Over the past 15 years, there have been some

organization gaps, partly because of the antivaccination movement. Vaccination being compulsory here is perceived negatively, while it is just recommended

in some EU countries and USA. But this is just a terminological trick, because unvaccinated children can’t be enrolled in any institution.“ – Key informant

„Germany has a recommended system of immunization, which is a lot more compulsory than our system, because the state has transferred responsibility to providers of services, such as kindergartens, schools, where children can get sick. So the first thing they ask when child is to be enrolled in kindergarten or

school is whether child was vaccinated. If not, child can’t be enrolled.“ – Key informant

„In some EU countries, parents are arrested and they pay big fines is child is not vaccinated. Anyhow, there are more vaccines in the EU.“ – Key informant

“France has 4 compulsory vaccines, vaccination is compulsory in Belgium, it is not compulsory in Flanders, and these people are genetically identical with

Dutchmen, but it’s a different culture. These are decent countries where experts and the state are trusted, while the south of Europe needs to make laws

stricter. There are various articles published, mortality after measles is 5-10% in poor countries, 25% in Africa, and this is connected with other diseases,

pneumonia.“ – Key informant

The expected trend of immunization coverageAll respondents agree that the coverage of immunization is decreasing – especially in case of MMR vaccine. Representatives of higher instances report of generally satisfactory coverage. However, both key informants and medical workers believe that the coverage will keep decreasing, and that only an epidemic may reverse the trend.

„The coverage is satisfactory. As for MMR, it has been decreasing over the years. Minimum 95% of the population should be vaccinated to prevent an

epidemic. The requirements are extensive in case of MMR.“ – Key informant

„They have the report for 2015, and soon they will have one for 2016 too. In one central Belgrade municipality, the coverage of MMR vaccine is only

50%, and we also have poor coverage in eastern and south-eastern Serbia. However, the coverage is satisfactory for majority of vaccines. 95% of the

population are covered by immunization eventually.“ – Key informant

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„ 80% of our children are vaccinated. The 20% less than 100% are MMR vaccine.“ – Paediatrician

„Our coverage is 83% , Stari grad has 65%, but let’s say that 17% are not vaccinated, that’s 1700 of 10.000, that’s 10.000 and 12.000 not vaccinated

children and in ten years the number will be 120.000 and it will burn as a twig“ - Paediatrician

When speaking of vulnerable populations, Roma children are most commonly specified as a group under the greatest risk of avoiding vaccination. Respondents identify various rea-sons for this – while some believe that the reasons are inaccessibility and non-respon-siveness of communities, others think that these populations are hard to reach and that their life style obstructs keeping comprehensive records or tracking of them.

„There are various barriers here, they have the poorest coverage with many healthcare activities, primarily due to ignorance and inaccessibility.“

– Key informant

„We used to conduct immunization in schools, and then moved to health centres, which made the situation complicated. Meanwhile, with the growing

crisis and suspicions, Roma people are increasing the distance from the health system, including immunization. We have tried to bring them back several times, but we failed, so our Roma population is rather poorly vaccinated,

without hope that things will get better. Even paediatricians send invitations, but to no avail.“

– Key informant

The experiences of female Roma mediator are a lot more positive. She states that coverage is better, but that Roma are generally still underinformed, some of them even leaving it to their children to decide whether they want to be vaccinated or not. However, the coverage of Roma population is expected to grow.

„Immunization has become a lot better in Roma population.“ – Female Roma mediator

„I had a family whose members didn’t want to vaccinate their child. And this lasted for 3-4 years. I wasn’t forcing them, but I always invited them to workshops. They finally vaccinated the child. There was also one case of the youngest child in the family. Other children received vaccines, and the

youngest was thought to be the healthiest and they thought there was no need for vaccination. The child was born at home so it was not registered either. We

dealt with it and the child was vaccinated eventually. „ – Female Roma mediator


Appendix 9

Full narrative report on focus groups

The perception of health system and health services, and parents’ prevention

Primary health centre is a place where all parents, irrespective of their attitude towards vaccination, seek healthcare services. Parents with positive attitude towards vaccination are more likely to mention preventive examinations, while parents with negative attitude towards immunization are more likely, before visiting their doctor, to try alternative treatment methods, such as teas and herbal syrups, as well as to read forums for information about their children’s symptoms. Roma parents perceive health centres as support, but they ad-dress them when child is sick, and not for prevention. All parents state that their children have a medical file in health centre, as well as a chosen doctor.

As for visiting private health institutions, this is certainly frequent among parents in general population, while parents from Roma population don’t have such experiences. Private health institutions are common choice for laboratory analysis, because it is easy to make appointments and obtain results quickly. Sometimes, private doctors are consulted for a second opinion or when child is to wait long for an examination in a state health institution. So parents mainly have positive attitude towards private doctors, while parents with negative attitude towards vaccination spontaneously do list the advan-tages of private services, but they have generally negative attitude towards all health-care services, either private or state.

„We don’t have to wait (in private healthcare institutions) and they are kinder and nicer, because they get paid for it. State institutions may offer better services than private do. Our doctor advised us to go to a private health

institution. We couldn’t make an appointment soon in a state institution. I am satisfied with the treatment and services.“

– Parent with positive attitude towards vaccination, urban area

The interviewed parents have different attitudes towards the health system and its staff. Parents who oppose vaccination emphasize having negative experiences in state health in-stitutions, such as with impolite staff, nurses first of all, inadequate doctors’ attention, long waiting time, and the process of making appointments.

„Nurses are very nervous, arrogant and impolite.“ – Parent with negative attitude towards vaccination, rural area

On the other hand, parents with positive attitude towards vaccination and Roma parents have somewhat rather positive attitudes towards healthcare institutions and their staff. Representatives of Roma population say that they have excellent communication and co-operation with paediatricians, while nurses are, again, specified as potentially unpleasant.

"Whenever I take him to the doctor’s, the nurse is frowned and impolite.“ – Roma mother

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Reports about experiences with medical workers who didn’t want to examine a child are mainly heard from representatives of Roma population – it usually happens when they miss their doctor’s shift, and then they are returned home.

„It depends whether it’s urgent, if child has fever they will see him .“ – Parent with positive attitude towards vaccination, urban area

„I was sent home because our doctor wasn’t there and nurse estimated that it was no emergency. If many people are waiting, and so do you, and they work till 20h, they won’t see anyone at 19.50h. Then they tell you to go to a very far

away hospital and you wait there again.“ – Parent with negative attitude towards vaccination, urban area

„You can’t see another doctor if your child has a fever. Come in the afternoon, it’s not a big deal, they ask how high fever is and send you home.“

– Roma mother

As for the perception of availability of health institutions, it is mainly positive. All parents agree that the problem is lack of internal organization in health centres and doctors’ work overload, which results in long waiting whenever they visit a health centre.

„It is impossible to find a free parking space. So I have to drive around in circles and wait. So my wife and child leave the car

and I keep driving until a find parking.“ – Parent with negative attitude towards vaccination, rural area

„It’s absolute collapse there. One paediatrician per shift.“ – Parent with negative attitude towards vaccination, urban area

„We have one doctor for primary school and kindergarten, there is no one else.“ – Parent with positive attitude towards vaccination, rural area

Finally, as for the activities of healthcare institutions aimed at inviting parents to preven-tive examinations of children, and vaccination, parents have different experiences. Parents with positive attitude towards vaccination of children state that they have been invited to regu-lar health check-ups only and never to vaccination. Their paediatrician enters in the vaccination booklet when they are to come for a vaccine, so they do it and no one invites them.

„We have never been careless so that they have to invite us.“ – Parent with positive attitude towards vaccination, urban area

Roma parents in Belgrade, Novi Sad and Požarevac, state that they haven’t been invit-ed by health centres, but that they have heard of other members of their community who were invited because they missed to vaccinate their children. Health mediators are


specified as important here, who often visit household together with doctors who vaccinate children on the spot. There are a lot more reports about such cases out of Belgrade. On the other hand, Roma fathers from Niš say that they have been invited by phone and in writing to bring their children for vaccination, because they were late.

„My child gets sick whenever it’s time for a vaccine. That’s not deliberate, it just happens and we have to postpone vaccination.“– Roma father

„I was warned that I would go to prison and pay a fine if we miss vaccination.“ – Roma father

Parents with negative attitude towards vaccination usually have been invited to vac-cination by healthcare institutions. These are mainly phone calls, and it’s important to mention that not all parents who are late with vaccination been invited. Only a few parents were delivered a written invitation.

„They didn’t call me, and I am still avoiding it. They threatened my neighbour with the Social Welfare Centre.“

– Parent with negative attitude towards vaccination, urban area

Knowledge, attitudes and practices of vaccination

Knowledge and attitudes towards vaccination

Spontaneously, parents usually mention tuberculosis, measles, hepatitis B, mumps as diseases that vaccination protects children from. The listed consequences of these dis-eases are usually sterility among men after mumps, as well as death because of measles, but also children’s paralysis and suffocating. Parents, however, unsystematically mention consequences, without associating specific diseases with them. Somewhat less informed are Roma parents, especially fathers, although many of them have heard of some of the consequences. On the other hand, opponents of vaccination usually consider mea-sles harmless, and vaccines as not guaranteeing protection. The attitude towards tuberculosis is similar, because they claim to know people who had tuberculosis, al-though they were vaccinated against it.

„I had measles and I am not vaccinated. I had pertussis and I am not vaccinated. I have no consequences today.„


In line with their initial attitude towards vaccination, parents have different opinions about whether it’s more adequate to treat children or vaccinate them preventively against some diseas-es. Quite expectedly, parents who support vaccination, but also parents from Roma popula-tion, prefer vaccination of children, while this is not so among parents who oppose vaccination. Namely, some of them believe that it is better to prevent some diseases with vaccines, but also that there is always risk that child will get sick anyhow. On the other hand, opponents of vaccina-tion say that they generally don’t oppose immunization of children, but that they need to be

245Appendices

sure about the given vaccines. At the same time, parents share strong, negative attitude to-wards MMR vaccine, which is considered to be a lot more harmful than beneficial, primarily be-cause of the supposed connection with autism. Finally, opponents of vaccination are extremely mistrustful towards pharmaceutical companies and the health system.

„I am not against immunization, I have a problem with guarantees given by the state. I want someone to say that it is 100 % guaranteed that my child will be

well. „ – Parent with negative attitude towards vaccination, rural area

„I can’t know whether my child will get sick of the diseases treated by that specific vaccine or some other. Doctors can’t know for sure whether this will

happen.“ – Parent with negative attitude towards vaccination, urban area

„Vaccines don’t prevent diseases. We receive a vaccine, but we also get sick.“ – Parent with negative attitude towards vaccination, rural area

„Treating of meningitis is very complicated, why risk catching meningitis when there is the possibility of vaccination.“


„He can get any disease if he doesn’t receive vaccines.“ – Roma mother

Speaking of epidemics, not many parents can specify concrete ones in the past which were stopped with vaccines. Quite expectedly, supporters of vaccination are better informed about these topics and they mention smallpox, tuberculosis, measles. Parents from Roma population mention flu, but also swine and avian influenza, while parents who op-pose vaccination mention just some of the diseases and doubt their causes – such as the re-cent epidemic of measles in Romania, which they consider a marketing trick designed to make parents vaccinate their children. At the same time, knowledge or lack of knowl-edge about past epidemics doesn’t influence the attitude towards vaccination. Majority of parents believe that epidemics may take place in the future, but parents with positive atti-tude towards vaccination are scared because of this, while majority of parents with negative attitude don’t worry much about this, believing that children can be cured from any disease.

„I have heard that those who don’t vaccinate their children will have to pay a fine. They want money from us. You have to be vaccinated for years in order to be protected from flu, and only from the past, not the future ones. And new types of flu keep appearing. Let’s all receive vaccines against avian influenza, next year we will have kangaroo flu, we will just keep on receiving vaccines.“ –

Parent with negative attitude towards vaccination, urban area

„We all start panicking whether measles will cause fever and affect lungs, it is quiet possible, there is no need to risk.“



„If we keep thinking about potential diseases, we will have to vaccinate children and give them medications all the time.“

– Parent with negative attitude towards vaccination, rural area

Parents from general population, both those with positive and those with negative attitude towards immunization, are familiar with the vaccination calendar. Parents who vaccinate their children have the vaccination booklet in which paediatricians write down the schedule of vaccination, or information about the received and scheduled vac-cines. Parents with negative attitude towards vaccination, but those who have vaccinat-ed their children, are also informed because they also have the vaccination booklet. However, parents with extreme attitude, those who have never vaccinated their chil-dren, strongly ignore everything about vaccination, including the vaccination calen-dar – some have the booklet because they were given one when child was born, but they ignore it, they don’t know when vaccination is due, and they don’t know all this because they are not interested. These parents are quite likely to say that they have never been given a brochure or calendar of vaccination in health centres. All Roma parents have immuniza-tion booklets, which they use to adhere to the time for vaccination, and they say that paediatricians talk to them about vaccination during health check-ups.

„Paediatrician informs me and writes down when it’s time for the next vaccine.“ – Parent with positive attitude towards vaccination, urban area

„I have no calendar of vaccination, I have seen some poster in the health centre.“


„There is a little piece of paper with information about vaccination and revaccination.“ – Roma mother

Parents who have vaccinated their children, both those with positive attitude towards vac-cination and those with negative attitude, claim that they are aware of the importance of following the immunization calendar. They believe that this calendar targets the most adequate time for vaccination, or time when child can develop the strongest immuni-ty to diseases. Roma parents share wrong belief that it is important that child receives all vaccines before starting school, while it is not very important when this takes place. Moreover, majority of parents from Roma population are not informed about the sched-ule of revaccination – mothers are better informed than fathers are. Some say that re-vaccination doesn’t take place at all, and that child gets new vaccine every time. On the other hand, it seems that the opinion of parents with negative attitude towards vacci-nation is strongly determined by the number of compulsory vaccines, including re-vaccination. Many consider this number too big and many don’t believe that this is nec-essary, thinking that this schedule is forced by the interests of healthcare institutions and pharmaceutical companies. Giving MMR vaccines is a specific issue – many parents wonder why this vaccine can’t be postponed until child starts to talk.

247Appendices

„This vaccination schedule is interesting. During the first 14-15 months, 14 vaccines. And until the age of 14 years…“

–Parent with negative attitude towards vaccination, urban area

„It is all the same when child will receive a vaccine. It is common practice here to vaccinate children at early age, so that children wouldn’t get sick. Injecting so many living viruses is scary, I won’t expose my two-week old baby to that. It is

fully protected. I won’t take it to a disco at that age.„ – Parents with negative attitude towards vaccination, rural area

Opinions about combined vaccines are somewhat specific. While some parents con-sider them acceptable because this is more comfortable, other parents believe that this is a problem because child’s reaction is more difficult to trace in this way, or to find out which of the vaccine ingredients causes reaction. Such different attitudes are equally pres-ent among all parents, irrespective of their initial attitude towards vaccination. At the same time, all parents agree that giving several different vaccines at once is not good for the child – it is not possible to track the effects of vaccines, and such application pro-vokes „chemical shock“ in child’s body.

„3 in 1, 5 in 1, 10 in 1, why not. The thing is whether they are going to have one or more injections, and we can’t know whether vaccine is of better quality. But

we trust the one who prescribed it.“ – Parent with positive attitude towards vaccination, urban area

„Several things together are never good. MMR is a combined vaccine and I fear this one most.“ – Parent with negative attitude towards vaccination, rural area

Concrete practices and experiences with vaccination

Parents who oppose vaccination behave in different ways – some of them have given their children all vaccines but MMR, which they are postponing, some gave only BCG vaccine after birth, or BCG vaccine and the vaccine against hepatitis B, while some have given all the planned vaccines to their children, but that they still have negative attitude to-wards them. All vaccines were received in health centre.

Parents from the population positive about vaccination state that application of vac-cines went smoothly, without problems, and that they detected mild reactions such as fever or mild redness, which were expected. They were familiar with these potential ef-fects because paediatrician informed them about this before giving vaccines, they collected information on their own, and finally they heard testimonials of other peo-ple. However, some parents state that vaccination is certainly traumatic and stressful for children, but that they are satisfied with paediatricians’ work.

Some parents from Roma population report about being afraid while their children re-ceived vaccines. They were afraid of the consequences because of the growing rumours about harmfulness of vaccines. On the other hand, none of the interviewed parents men-tioned serious complications after receiving vaccines – there was some redness,


fever, swelling and mild rash that disappeared quickly. Parents who oppose vacci-nation and who have given some vaccines, have different experiences. Some mention the same reactions of children as parents from general population and Roma parents do, while others mention more serious reactions, which provoked even more severe suspicion. In addition, some of these parents react a lot more negatively to the expected reactions than supporters of vaccination do.

„My older daughter received the vaccine that she was to receive when she was 2 months old, when she was 4.

She instantly turned blue and started to suffocate.“ – Parent who opposes vaccination, urban area

„There were no adverse effects, everything was ok, but it was harder for us than for the child, we were stressed thinking what was going to happen.“

– Parent who opposes vaccination, rural area

„It was terrible when my child received a vaccine, I cried more than he did.“ – Parent who opposes vaccination, urban area

In line with their initial attitude towards vaccination, parents have different opinions re-garding vaccinating children with compulsory vaccines. While parents who support vaccination and parents from Roma population believe that all vaccines are necessary, parents with negative attitude towards vaccination share an opposite attitude. These parents believe that a significant problem is the very schedule of immunization and the number of vaccines children are to receive at the youngest age. The biggest prob-lem at this moment is provoked by MMR vaccine, which majority of parents who op-pose vaccination consider unnecessary. These parents either believe that there is a connection between this vaccine and autism or they are simply not sure about this, so they choose to avoid this vaccine until it becomes clear whether this connection exists. Those parents with the most extreme attitude against vaccination and those who haven’t vaccinated their children, strongly oppose application of BCG vaccines right after birth, without asking the parents. Such rules make these parents suspicious and mistrustful, because they believe something is kept hidden from them. Some who are planning to have more children are even thinking about the ways to prevent giving of BCG vaccines to their future children. Finally, some parents who oppose vaccination are quite suspicious about the origin of vaccines, given that they don’t have much confidence in import-ed vaccines.

„Some say that child can become autistic after this vaccine. I certainly won’t give it to my child.“ – Parent with negative attitude towards vaccine, urban area

„I heard bad stories about Polio vaccine, and I was afraid when I realised that my son received it. I wouldn’t have allowed it if I knew all this.

If child is vaccinated, something may happen, if child isn’t vaccinated, something may happen too.“

– Parent with negative attitude towards vaccine, rural area

249Appendices

„Since Torlak is not working anymore, who knows where these vaccines come from.“ – Parent with negative attitude towards vaccine, rural area

All parents claim that they have been in a situation, at least one time, that vaccine wasn’t available in health centre or that they were recommended to buy a vaccine. Parents explain how paediatricians or nurses contacted them directly or by phone and informed them that vaccines were late, or they were suggested to buy vaccines in the pharma-cy. It used to be unclear whether parents were to buy Pentaxim or not. Doctors used to recommend them to buy it, which majority of parents with positive attitude towards vac-cine did. Parents with negative attitude towards vaccination, who had already given some vaccines to their children, have different experiences with purchase of vac-cines. Some say that they bought vaccines because it was recommended by their doctor, while others bought them because they heard about children’s milder reaction to them.

„I bought it. I thought it was better. I can’t remember which one. They told me the child wasn’t going to have a fever.“


Parents from Roma population remember that in 2013-2014. there was a shortage of vaccines and that they had to wait for 6 months for them. However, they don’t know which vaccine this was. In addition, some of these parents were offered to buy Pentaxim before it became compulsory – some purchased this vaccine, others waited until it became avail-able in health centres.

„The vaccine Pentaxim was not available. He was to receive three. One to drink, two to have injected. I could buy it in pharmacy for 5 000 rsd. If not, I

could wait for them to call me. I waited and they called.“ – Roma mother

However, in general, parents have more positive attitude towards vaccines provided by health centres than towards those purchased in pharmacies. The exception among parents with positive attitude towards vaccination are the situations when paediatricians ad-vise parents to buy vaccines. These are usually the parents who believe that there are no differences between these vaccines, so they do what doctor tells them to. Parents with neg-ative attitude towards vaccination are more likely not to see any difference between these vaccine, but they would rather opt for vaccines from health centres because they wouldn’t have to worry about their storing.

„I was suggested to buy it in pharmacy, I didn’t want to because I didn’t know who the producer was, the vaccine is foreign and I didn’t know whether it was controlled by Torlak, so I trusted our vaccine in health centre more. This was

only in 2011. with the youngest child, and it was not possible to buy it after that.“ – Roma mother

In general, majority of parents with positive attitude towards vaccination postpone vaccina-tion because of child’s sickness. Two of all the interviewed parents with positive atti-tude towards vaccination say that they have postponed vaccination out of fear, MMR vaccine both. One of these parents didn’t inform the doctor about this decision, but


lied how child was sick, while the other one postponed vaccination because the doc-tor recommended it. Roma parents usually postpone vaccination due to sickness. As it was mentioned, some parents forgot to vaccinate their children after postponing, but they were reminded by health centres on time and informed that it was time for vaccina-tion. Parents with negative attitude towards vaccination are likely to postpone vaccination, MMR again. Some have postponed it for several times, but still haven’t made a solid de-cision whether to vaccinate their child or not, because they are waiting until child reaches certain development phase (for instance start to speak). These parents also report that they have heard of cases of autism after receiving MMR vaccine, which made them suspect. These parents mainly avoid vaccination, while some have told their paedia-tricians openly that they didn’t want their children to receive this vaccine.

„I did postpone vaccination. A child of our friends, absolutely normal, becomes autistic after receiving the vaccine. I waited for my child to speak, and

gave the vaccine at the age of two.“ – Parent with positive attitude towards vaccination, urban area

„I wasn’t lying, I just said that I didn’t want my child to be vaccinated. The doctor said – Find another paediatrician, all my children are vaccinated. I

can’t say anything against her, she treated my first child. When we said that we didn’t want to vaccinate our second child, she said goodbye. She rejected us

and told us to find someone more liberal.“ – Parent with negative attitude towards vaccination, urban area

„You simply don’t come to vaccination and that’s it. She still has time to receive it.“

– Parent with negative attitude towards vaccine, rural area

„I’m cunning. I always say that my child is sick. Let them sign that they are responsible for the vaccine and that child can receive it. But no own will sign.“


Almost none of the interviewed parents with positive attitude towards vaccination have ex-periences with signing forms for accepting vaccination, as well as Roma parents. Only some parents with negative attitude towards vaccination have signed this form, but their attitude towards forms is generally negative.

„It is not pleasant. Wherever we go, in whichever state institution, everyone roles their eyes when we say that our child is not vaccinated.“


„We had to find another paediatrician, they called us on the phone, they pressured us in kindergarten, called us from health centre.

They finally enrolled the child in kindergarten without vaccination.“ – Parent with negative attitude towards vaccination, urban area

251Appendices

The perception of advantages and disadvantages of vaccination

Parents with positive attitude towards vaccination believe that vaccination has numer-ous advantages: prevention of epidemics, precaution, psychological stability, protec-tion of the child and the whole society. Roma parents are less fluent about the advan-tages of vaccination, but they generally mention protection of immunity, or prevention.

Disadvantages of vaccination are various: A) parents with positive attitude towards vacci-nation say that the major disadvantage, at this moment, is negative propaganda against vaccination, and no clear information or denial from professional public. B) another dis-advantage is absence of guaranteed protection from diseases after vaccination. C) third disadvantage is absence of unique attitude of medical workers towards vaccination, so respondents have heard of medical workers who oppose vaccination, which additionally disturbs parents from general population.

„Downside is lack of information, they keep talking negatively about immunization in public, and these are all speculations.“


„In my family, the same paediatrician told mother not to vaccinate her child and after a year he said that she should vaccinate her child, which means that

they also have dilemmas. What are we to do when we don’t know anything about this?“

- Parent with positive attitude towards vaccination, rural area

„The doctor told me to decide, but how can I decide when I’m an amateur.“ - Parent with positive attitude towards vaccination, urban area

Parents with negative attitude towards vaccination have different attitude. Those who have given some vaccines to their children say that major advantages are collective im-munity and rooting out of diseases. Parents with extremist attitude see no benefits in vaccination. The perceived disadvantages primarily refer to the existing legal frame that stipulates compulsory vaccination, fines for not doing so, no information about vac-cines, the composition of vaccines, the fact that vaccines are imported, and proof that vaccines are simply neither beneficial nor good. Some of these parents, especially those who are having doubts about vaccination in the future, criticize the lack of pos-itive propaganda about vaccination and its benefits.

„Because I believe that this vaccine is not good. I am convinced that this vaccine is not good. People have been talking in the media a lot.

I can’t know whether these are some affairs, or if they have any gain from this. This is compulsory only here and people may be punished. That girl became

deaf after receiving a vaccine, so we decided not to take that rubbish, but they explained how the vaccine was not to blame.“



„This lack of information bothers me. If you are forcing us to vaccinate our children, at least tell us everything about the adverse effects.“


„They say that it is compulsory for enrolment in school. Producers don’t react, and the state conditions us. So, no one is to blame. Children become unable to live. They give assistance 3-4000 rsd a month. Parents can’t work. Some study

suggests that, in the 80s, autism was 1:10.000, and now it’s 1:50.000.“ – Parent with negative attitude towards vaccination, rural area

„Why should my child be a guinea pig.“ – Parent with negative attitude towards vaccination, rural area

„Everything is unsafe, we don’t know what’s inside, no one shows you the shelf life or tells you anything.“


Parents with positive attitude towards vaccination are very likely to state that they would recommend vaccination, although some of them wouldn’t like to recommend anything and would like to leave the decision to parents. They know parents who hav-en’t vaccinated their children, but they try not to talk to them about it and respect their de-cision. Parents from Roma population mainly say that they would recommend other parents to vaccinate their children, because of prevention and better immunity.

„I have nothing to say about that, they are not informed well enough and it’s their choice, I won’t persuade anyone.“


„This is a very sensitive topic and it is very hard to advise someone about what is better for their child, because it turns out that you want

something better for that child than parents themselves.“ - Parent with positive attitude towards vaccination, rural area

„Both attitudes should be accepted and not discussed.“ – Parent with positive attitude towards vaccination.

Parents with negative attitude towards vaccination say that they would advise other parents either not to vaccinate their child or to get informed how harmful vaccination is, and then make the decision on their own.

253Appendices

Making decisions

Numerous parents, even those with positive attitude towards vaccination, report of their strong doubts about vaccination. The decision to vaccinate their child is usually made together with their spouse – similar to parents from Roma population. Parents who haven’t vaccinated their children say that this decision was easy, guided by their mis-trust in vaccines, although some found it hard to make this decision, which was dis-cussed for long and extensively with many family members.

„We simply sat down and agreed not to vaccinate our child. It was very risky, given the waiting time. My child was sick and the available period simply passed.“ – Parent with negative attitude towards vaccination, urban area

The media, the internet, but also examples of people whose child got sick after receiving a vaccine – usually some form of autism after MMR vaccine, have their influence. Although not all trust the media to an equal extent, many consider personal experiences of other peo-ple crucial for the direction of their decision.

Many parents have consulted their paediatrician in order to resolve their doubts about vaccination. Some paediatricians support vaccination openly, while others take neutral attitude, saying that parents have the right to decide whether they will vaccinate their children or not. Those with negative attitude towards vaccination also say that some medical workers told them how they wouldn’t vaccinate their children or that they were not sure what to recommend to parents.

Attitudes towards different aspects of vaccination

The attitude towards mechanisms for control of vaccine quality is largely influenced by the general attitude of parents towards the health system in Serbia. Negative attitude is present even among parents who have vaccinated their children, and these parents also seem to lack information about the mechanisms of control, which would make their attitude more positive. On the other hand, parents from Roma population have no negative attitude, but they say that they would surely like to have more information about this topic. Quite expectedly, also parents with negative attitude towards vaccina-tion don’t trust or lack information about the mechanisms of vaccine control.

„ I have heard of affairs in pharmacy, such as that with Pentaxim, how they store it and how it should be stored, everything is doubtful.“


„I generally don’t trust the vital state institutions, healthcare among other, courts, the Police.“

– Parent with positive attitude towards vaccination, rural area

„I don’t doubt their knowledge, I just want strict control of the place of origin.“ – Parent with positive attitude towards vaccination, urban area


„We don’t know who is responsible for quality, let alone how it works.“ – Parent with negative attitude towards vaccination, rural area

„I don’t trust my state. The state should take care of me, of its citizens, of my child. I don’t want to think about shelf life of that vaccine, or whether it is

the right one. Do I trust them? Of course not.“ – Parent with negative attitude towards vaccination, urban area

It is quite interesting that all parents share significantly more positive attitude towards local over imported vaccines. Parents from general population state that they are a lot more suspicious about the import process, the way these imported vaccines are stored and the way producer of vaccine is selected. The attitude towards Torlak certainly used to be more positive in the past, and even parents with negative attitude towards vaccination state that they had no doubts while Torlak produced vaccines. As for foreign vaccines, there is no single attitude about the preferred country for import of vaccines – respondents mention Germany and Russia, while they have somewhat more negative attitude towards vaccines from America. Moreover, this is not a topic parents talk about with paediatri-cians or other medical staff.

„There was rumour about a whole wave of children who became autistic because of some vaccines imported from America.“

– Parent with positive attitude towards vaccination, rural area

„Big companies are chasing profit, while we had state institutions that worked irrespective of profit.“


„Pharmaceutical companies force something bad. Things were different when everything was right and when things worked properly.

There is not enough control now.“ – Parent with negative attitude towards vaccination, rural area

Should vaccination be compulsory, are there alternatives and how to overcome barriers?

According to many parents with positive attitude towards vaccines, vaccination should be compulsory in Serbia – because of growing number of parents who oppose vaccination, and to prevent epidemics. This opinion is also shared by parents from Roma population, who say that child protection is the priority, even if it means forcing some parents by legal means. Parents with negative attitude towards vaccination mention other countries where vaccination is not compulsory and believe that Serbia should follow their example. Although regulations stipulate that child can’t be enrolled in school if not vaccinated, this regulation is not observed.

255Appendices

„If vaccine weren’t compulsory, 90% of people wouldn’t vaccinate their children.“


„It should be legally binding because of children’s safety, because our people are easily mislead, when one says so,

no one wants to, and no one knows why.“ – Roma mother

In addition, it seems that the system of punishing parents who refuse to vaccinate their children doesn’t play much of a role in the decision-making process about vacci-nation. These parents say that no fee is large enough to make them change their opinion about vaccines.

„I am to give up on my principles for 150000. And average salary is 48000. All the people I know work for 25000. How will they charge this 150000?“


„Switzerland produces vaccines, and they are not compulsory there. We import them and they are compulsory. What is there to say more? “


MMR vaccines surely provoke most serious worry at the moment and everything men-tioned seems to obstruct influencing such citizens’ perception. For those parents who are still having doubts, a significant question is why MMR can’t be postponed, or why it has to be injected before child speaks – this is the reason why some parents deliberately post-pone giving this vaccine. Furthermore, parents with negative attitude towards vacci-nation state that MMR vaccine is forbidden in some countries, which supports their doubts in the benefits of this vaccine. The attitude of health institutions and relevant bodies towards this issue is unclear, so there is no positive communication of pro-fessional public that may stimulate positive attitude of parents towards this vaccine.

„When, in the parenting school, paediatrician tells you that he is not sure whether child should be vaccinated, what am I think?„


„MMR contains mercury. And they inject it in you. It’s nsane.“ – Parent with negative attitude towards vaccination, urban area

Finally, speaking about alternative medicine, all parents share generally positive attitude towards consumption of herbal teas and drops for disease prevention. Parents with positive attitude towards vaccination and Roma parents still believe that vaccination of children has no substitute. Parents with negative attitude towards vaccination, although they are not sure that alternative medicine can be adequate substitution for vaccines, generally believe that it can improve child’s immunity to a great extent, which will keep child healthy.


Sources of informationCommunication with paediatricians is perceived differently. Some say that paediatricians are interested in providing information about vaccines, while others disagree and believe that paediatricians are not educated and interested enough. Besides paediatricians, parents also consult other parents about this, their close ones, but they also browse the internet, forums and social networks. Internet consumption is especially frequent among parents with negative atti-tude towards vaccination, while for instance Roma parents report collecting information from the media about harmfulness of MMR vaccines. However, they haven’t changed their decision to vaccinate their child because they thought it was in the best interest of the child, and it was also advised by their paediatrician. However, Roma parents are more likely to state that paedia-tricians don’t have enough time for them and that they need to ask paediatricians for addition-al explanation several times, but they still don’t have negative attitude towards paediatricians.

Parents with positive attitude towards vaccination and Roma parents trust paediatri-cians, while parents with negative attitude towards vaccination don’t trust anyone or trust people with experience with vaccination - those with negative experience.

„When the time comes, he talks to us. He explains what this vaccine is and what it is for. But he doesn’t talk about this when it is not time for vaccination.

There are other problems to address. He has no time for everything. They explain what vaccine is for, what the adverse effects are.“


Internet and TV are common sources of information about vaccines among parents with negative attitude towards vaccines. Parents with positive attitude towards vaccines say that they try not to detect information about this topic, because they don’t trust the informa-tion on the internet, so they try to minimize their influence. Parents from Roma population don’t have uniform attitude regarding whether they get informed about these topics through the media or not.

„I don’t trust anyone. I have seen the program and listened to that mother and I don’t believe it. I firmly believe that the truth is on the websites where moms

write about their experiences.“ – Roma mother

„No one tells us in the news, on TV, that immunization is compulsory, but we are responsible for that. There is no such information available.“ – Parent with negative attitude towards vaccination, rural area

When they are exposed to an example of a mother with negative experience after vacci-nation, all parents empathise, and parents with negative attitude and Roma are more likely to consider doctors responsible, while parents with positive attitude consider doctors and mother responsible. As they say, child should have been examined adequately before vac-cination, but also mother should have been better informed about vaccines. As for the ex-ample of communication of paediatrician, parents with negative attitude towards vaccination mainly don’t trust the paediatrician, while other parents react positively to doctor’s reaction

257Appendices

„I would be happy if a paediatrician talked to me like this.“ – Parent with negative attitude towards vaccination, urban area

„They have become skilled in persuading us, it is in their interest that paediatricians have as many children vaccinated as possible.

I don’t find it credible, supported, these are all assumptions. But these arguments are not persuasive.“


„I know a doctor who didn’t vaccinate his child. Because of this 1% possibility of adverse effects. Even this 1% is disastrous.

Those unfortunate ones fall among these 1%. „ – Parent with negative attitude towards vaccination, rural area

„I believe that larger number of children have had problems with autism than they are telling us. This sounds biased.“


Parents with positive attitude towards vaccination perceive themselves as medium informed and they believe that parents in Serbia are generally uninformed. Parents from Roma population see themselves as even less informed about this issue, while par-ents with negative attitude towards vaccination are somewhat more likely to believe that they are uninformed – only parents who strongly oppose vaccination describe themselves as very well informed.

„When time comes to be vaccinated, I pay some more attention, but I am not informed in general.“


„Owing to social networks, I suppose, everything is available to us. The question is whether things would be different if vaccines were of higher quality,

different, better. There was autism before, but no one knew about it, no one talked about it. It was different, healthier, better. We are in a vicious circle now.

We don’t know what to do.“ – Parent with negative attitude towards vaccination, rural area

Parents state that professionals, representatives of higher instances, the Ministry of Health for instance, but also doctors, are directly responsible for providing more information about vaccination. All parents say that they would like to know more about quality of vac-cines, composition of vaccines and clear list of adverse effects, with focus on MMR and its connection with autism.


„Doctors make most of this mess and confusion because they should inspire trust. One says I support MMR, another says I don’t, so you ask yourself who to

trust.“ – Parent with positive attitude towards vaccination, urban area

„It seems like becoming stronger rather than scaling down. Fanatic groups, conspiracy, they will kill us with vaccines. There are also those who are really worried and having doubts. Show me why I should have my child vaccinated.

And I also believe that this is just a trend.“ – Parent with negative attitude towards vaccination, urban area

The preferred methods for obtaining additional information about vaccines: promotional ma-terials, brochures, media programs, but also organized lectures within Parent Counselling office, or health centres. Parents from Roma population state that it would be very useful to focus on pregnant women and start education about vaccines during pregnancy.

„It would mean a lot if some credible expert explained in public all the advantages and disadvantages. Without reserve.

Someone experienced in the field. Our expert.“ – Parent with positive attitude towards vaccination, rural area

„We trust doctors more than we trust media, internet and forums. If doctors really offered us something concrete, perhaps more of us would

opt for vaccines.“ – Parent with a negative attitude towards vaccination, urban area

„Each mother in the maternity hospital should get a flyer with explanation. She should be educated and read during pregnancy too.“ – Roma mother

259Appendices

Appendix 10

Results of regression analysis

Dependent variables: Knowledge about immunization, Vaccine Consiprancy Scale, Media Literacy, Myths and Risks

Model Summary

Model R R Square Adjusted R Square

Std. Error of the Estimate

1 .592(a) 0.350 0.346 0.487

ANOVA(b)

Model Sum of Squares df Mean

Square F Sig.

1

Regression 117.666 5 23.533 99.197 .000(a)

Residual 218.574 921 0.237

Total 336.240 926

Coefficients(a)

Model

Unstandardized Coefficients

Standardized Coefficients t Sig.

B Std. Error Beta

1

(Constant) 0.266 0.061 4.359 0.000

Risks 0.021 0.003 0.342 8.110 0.000

Myths 0.003 0.002 0.053 1.259 0.209

Media literacy -0.008 0.004 -0.056 -1.972 0.049

Knowledge 0.017 0.010 0.050 1.784 0.075

Vaccine conspiracy

scale0.027 0.004 0.267 6.771 0.000


Dependent variables: Confidence in science, Confidence in Medical Authorities, Support of envrionment

Model Summary



1 .441(a) 0.195 0.192 0.534

ANOVA(b)


Square F Sig.

1

Regression 67.272 3 22.424 78.757 .000(a)

Residual 278.176 977 0.285

Total 345.447 980

Coefficients(a)

Model



B Std. Error Beta

1

(Constant) 2.512 0.099 25.341 0.000

Confidence in Medical Authorities

-0.032 0.004 -0.252 -7.180 0.000

Confidence in science 0.013 0.005 0.077 2.475 0.013

Support of envrionment -0.033 0.004 -0.281 -8.366 0.000

261Appendices

Dependent variables: Total number of children aged 18 and below in household, Age, Education, Type of Settlement and Financial situatuion

Model Summary



1 .126(a) 0.016 0.010 0.593

ANOVA(b)


Square F Sig.

1

Regression 5.246 5 1.049 2.985 .011(a)

Residual 327.048 930 0.352

Total 332.294 935

Coefficients(a)

Model



B Std. Error Beta

1

(Constant) 1.355 0.132 10.230 0.000

Total number of children aged 18

anf below

-0.002 0.025 -0.002 -0.064 0.949

Age -0.010 0.019 -0.019 -0.553 0.581

Education 0.016 0.034 0.016 0.455 0.649

Type of settlement -0.136 0.042 -0.110 -3.242 0.001

Financial situatuon 0.031 0.023 0.047 1.354 0.176


■ Title explains the variable whose relative frequencies are given in the table.

■ Total in the first column shows percentages for each category of the tabulated.

■ Each next column represents percentages of the given variable within some subpopulation.

■ Row marked with N denotes size of the base, i.e., the size of (sub) sample on which the percentages are calculated.

■ Row marked with sig, represents significance of Hi-square statistics of the observed variable and variable from columns, if hi-square is significant, sig-nificance is written in white letters.

■ The last row in the table 100% indicates that all values in columns are added up to 100, that is, that column percentages are given.

Education-the last finished school:Total Gender Type

N 1198 599 599 704 494

sig 0,00 0,00

No formal education 1,8 2 2 1 2

1 to 7 grades of primary school 5,1 4 6 3 8

Primary school (completed, 8 grades) 19,4 17 22 14 27

One-two year vocational school 1,3 1 2 1 1

Three year vocational school 11,8 15 9 10 14

Four year vocational school 40,4 41 39 44 35

High school 4,6 4 6 6 3

College, first degree of university 6,3 8 5 7 5

Faculty, academy 8,8 8 10 12 4

Master's degree 0,3 0 0 1

Doctorate 0,2 0 0 0

Total 100%

Appendix 11

How to read tables

263Appendices

Cells of the table are colored in blue, or red, if values they contain are consid-erably above or below the average. Three shades of blue or red color are used for three degrees of significance, the lightest shades for deviations significant on the level 0.10, medium shades for the level 0.05 and the darkest shades of blue and red for the level 0.01.

Example of interpretation of data from the above table (structure of education):

■ Significance of hi-square (significance of both hi-squares of statistics is less-er than 0.01) tells us that distribution of education by gender/ type of settle-ment differs significantly.

■ Glimpse at the cells of the table shows that there are significantly more males with three year vocational school on the level of significance 0.05 (total num-ber of respondents in the sample with this type of education is 11.8%, and among males 15%). Similarly, there are significantly less females with this type of education (on the level 0.05) 9%.

■ There are significantly more respondents with faculty, academy (level 0.01) in urban settlements compared to entire population (12%), and significantly less in other types of settlements (the same level of significance 0.01) that is, 4%.

Above average Average Below average

0,01 0,05 0,10 0,10 0,05 0,01


Please assess general situation in the country on the scale 1 to 5

Total Gender

Muš

ki

Žens

ki

N 1013 500 513

sig 0,13

Grade 1 23,1 23 23

Grade 2 35,3 37 34

Sum - 58,4 59 57

Grade 3 35,1 35 36

Sum + 4,9 5 4

Grade 4 3,9 4 4

Grade 5 1,0 1 1

Refusal 0,5 1 0

Doesn’t know 1,0 0 2

Total 100%

Mean 2,23 2,24 2,23

Which brands do you know?

Total Type

Urb

an

Oth

er

N 502 302 200

Brand C 97,8 98 98

Brand A 93,2 95 91

Brand D 39,1 41 36

Brand B 22,3 26 17

Brand E 22,1 19 27

Other 20,9 26 14

I don't know any 0,2 0

■ If tabulated variables represent the respondent's assessment on some scale 3 more rows are added.

■ Row marked with Sum - represents the sum of percentages on negative.

■ Row marked with Sum + represents the sum of percentages on positive grades.

■ Rows below grades con-tain other non-specific an-swers of the respondents.

■ Row marked with Mean represents arithmetic mean of the given grades.

■ In case of multiple re-sponse (the respondent can give several valid an-swers, modalities) data in cells represent a percent-age of (sub) population which mentions, that is, answers positively to giv-en modality.

■ Please note that row 100% is missing – that is because percentages do not add up to 100%.

265Appendices

Appendix 12

Statistical tables – crosstabs with demography

Tables 12.1.,12.2.,12.3.,12.4.

Reported vaccination behaviour (whether parents followed the schedule of vaccination for their youngest child) is not determined by socio-demographic characteristics, not in Roma or in general population. In general population higher educated people were somewhat more likely to delay some vaccines.

Past and future vaccination behaviour, however, are closely related: out of those who will vaccinate regularly, 98.6% reported to have vaccinated following the schedule, out of those who will give some and avoid other vaccines, only 33% report to have followed the schedule.

Tables 12.5., 12.6.

No radical differences in vaccination experience emerged when respondents’ answers were broken down by age, education, region, employment and financial situation. In general pop-ulation, parents from Belgrade reported somewhat more frequently that they had a ques-tion that wasn’t addressed by medical stuff, and that a child had a strong adverse reaction to a vaccine.

Hesitant parents who will give only some vaccines report more frequently that they had an unanswered question and less frequently that they were informed about possible adverse reactions.

Tables 12.7., 12.8.

When assessment of vaccine-related risks was analysed by socio-demographic data, again the same pattern emerged: only education and region were somewhat significant in gener-al population. Less educated parents reported to be less worried about side effects of vac-cines, other diseases that can be triggered by vaccination, risks about multiple vaccines in one shot or too early age for vaccinating. Belgrade parents reported to be more worried about all those issues, in comparison to parents from Vojvodina, who seem to be less wor-ried. No significant differences by these variables were found in Roma population.

As expected, hesitant parents reported to be more worried about vaccine-related risks and less willing to have vaccination mandatory by law.


Table 12.1 – PAST behaviour - Which of the following is true for your child (if more children. for your youngest child) – Roma population

N N u

nw

sig

% w

ho va

ccin

ated

th

eir ch

ild

% w

ho w

ere h

esita

nt.

but s

till v

accin

ated

% w

ho al

lowe

d on

ly so

me v

accin

es

% w

ho re

fuse

d va

ccin

atio

n co

mpl

etely

210 209 92.3 4.3 3.0 0.4

Gen

der Male 2* 2*

1.00100 0.0 0.0 0.0

Female 207 207 92.2 4.4 3.1 0.4

Age

cate

gory Up to 30 y. 153 162

0.0693.0 2.7 4.2 0.1

More than 30 y. 56 47 91.7 5.7 2.1 0.5

Educ

atio


0.11

96.2 0.9 2.9 0.0

Secondary 18 14 93.9 3.2 2.6 0.3

Faculty 0** 0** 87.5 7.9 3.9 0.6

Type

of

settl

emen

t

Urban 153 1440.01

90.3 6.1 3.3 0.3

Rural 56 65 95.8 1.2 2.6 0.5

Reg

ion

Belgrade 39 40

0.73

90.5 4.8 4.0 0.8

Vojvodina 31* 26* 95.2 2.4 2.4 0.0

Central Serbia 139 143 91.6 5.1 2.9 0.3

Empl

oym

ent

stat

us

Employed 14* 12*

0.26

92.2 5.3 2.2 0.4

Unemployed 113 112 90.8 2.7 5.8 0.8


Fina

ncia

l si

tuat

ion

Low 138 138

0.91

93.5 3.7 2.6 0.2

Medium 46 47 92.7 4.3 2.6 0.4

High 21* 21* 89.9 5.3 4.3 0.5

Futu

re b

ehav


0.00

98.6 0.9 0.4 0.0


Will give some vaccines 3* 3* 32.9 29.5 37.6 0.0


Base: Total target population

*:N<25. data is not analysed, **: No data.

267Appendices

Table 12.2 – PAST behaviour - Which of the following is true for your child (if more children. for your youngest child) – General population

N N u

nw

sig

% w

ho va

ccin

ated

th

eir ch

ild

% w

ho w

ere h

esita

nt.

but s

till v

accin

ated

% w

ho al

lowe

d on

ly so

me v

accin

es

% w

ho re

fuse

d va

ccin

atio

n co

mpl

etely

821 821 92.3 4.3 3.0 0.4

Gen

der Male 8* 9*

1.00100 0.0 0.0 0.0

Female 813 812 92.2 4.4 3.1 0.4

Age

cate

gory Up to 30 y. 368 357

0.0693.0 2.7 4.2 0.1

More than 30 y. 453 464 91.7 5.7 2.1 0.5

Educ

atio


0.11

96.2 0.9 2.9 0.0

Secondary 481 467 93.9 3.2 2.6 0.3

Faculty 243 293 87.5 7.9 3.9 0.6

Type

of

settl

emen

t

Urban 524 5440.01

90.3 6.1 3.3 0.3

Rural 297 277 95.8 1.2 2.6 0.5

Reg

ion

Belgrade 191 212

0.73

90.5 4.8 4.0 0.8

Vojvodina 215 226 95.2 2.4 2.4 0.0

Central Serbia 415 383 91.6 5.1 2.9 0.3

Empl

oym

ent

stat

us

Employed 411 435

0.26

92.2 5.3 2.2 0.4

Unemployed 177 166 90.8 2.7 5.8 0.8


Fina

ncia

l si

tuat

ion

Low 165 153

0.91

93.5 3.7 2.6 0.2

Medium 383 385 92.7 4.3 2.6 0.4

High 207 223 89.9 5.3 4.3 0.5

Futu

re b

ehav


0.00

98.6 0.9 0.4 0.0


Will give some vaccines 37 37 32.9 29.5 37.6 0.0



*:N<25. data is not analysed,


Table 12.3 – Future behaviour - Roma population

N N u

nw

sig

I will

certa

inly

get h

im/

her v

accin

ated

follo

wing

th

e sch

edul

e.

I will

prob

ably

get h

im/

her v

accin

ated

follo

wing

th

e sch

edul

e.

I will

get h

im/h

er va

ccin

ated

fo

r som

e vac

cines

. and

re

fuse

the o

ther

s.

I will

refu

se to

get

him

/he

r vac

cinat

ed at

all.

Don't

know

. ref

usal

211 211 85.3 9.3 1.7 1.6 2.2

Gen

der Male 2* 2*

1.0055.8 44.2 0.0 0.0 0.0

Female 209 209 85.6 8.9 1.8 1.6 2.2

Age

cate

gory Up to 30 y. 154 163

0.8586.8 7.8 2.4 0.9 2.1

More than 30 y. 57 48 81.1 13.1 0.0 3.5 2.3

Educ

atio


1.00

84.6 9.4 1.9 1.8 2.4

Secondary 18* 14* 92.4 7.6 0.0 0.0 0.0

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 1451.00

86.1 9.5 2.4 0.0 2.0

Rural 57 66 83.0 8.6 0.0 5.9 2.4

Reg

ion

Belgrade 39 40

0.99

89.0 11.0 0.0 0.0 0.0

Vojvodina 31 26 100 0.0 0.0 0.0 0.0

Central Serbia 140 145 80.9 10.8 2.6 2.4 3.2

Empl

oym

ent

stat

us

Employed 14* 12*

0.95

63.3 17.1 0.0 9.8 9.8

Unemployed 113 113 84.0 11.0 1.6 1.8 1.6


Fina

ncia

l si

tuat

ion

Low 139 139

1.00

83.4 10.3 1.3 2.4 2.6

Medium 47 48 86.9 11.2 2.0 0.0 0.0

High 21* 21* 91.0 0.0 4.5 0.0 4.5

Futu

re b

ehav


0.00

100 0.0 0.0 0.0 0.0


Will give some vaccines 4* 4* 0.0 0.0 100 0.0 0.0




269Appendices

N N u

nw

sig

I will

certa

inly

get h

im/

her v

accin

ated

follo

wing

th

e sch

edul

e.

I will

prob

ably

get h

im/

her v

accin

ated

follo

wing

th

e sch

edul

e.

I will

get h

im/h

er va

ccin

ated

fo

r som

e vac

cines

. and

re

fuse

the o

ther

s.

I will

refu

se to

get

him

/he

r vac

cinat

ed at

all.

Don't

know

. ref

usal

824 824 79.0 13.8 4.4 1.0 1.8

Gen

der Male 8* 9*

1.0082.8 17.2 0.0 0.0 0.0

Female 816 815 79.0 13.7 4.5 1.0 1.8

Age

cate

gory Up to 30 y. 370 359

0.5979.7 12.0 4.8 1.1 2.3

More than 30 y. 454 465 78.4 15.2 4.2 0.9 1.4

Educ

atio


0.91

82.2 16.0 0.9 0.0 0.9

Secondary 483 469 80.0 12.2 5.1 1.1 1.5

Faculty 244 294 75.7 16.0 4.4 1.1 2.7

Type

of

settl

emen

t

Urban 525 5460.01

75.1 16.7 5.1 1.1 2.1

Rural 299 278 85.9 8.7 3.3 0.8 1.3

Reg

ion

Belgrade 194 215

0.82

76.8 12.9 5.2 1.1 3.9

Vojvodina 215 226 84.7 10.8 4.1 0.0 0.4

Central Serbia 415 383 77.0 15.7 4.3 1.4 1.5

Empl

oym

ent

stat

us

Employed 411 435

0.77

80.4 12.1 5.1 1.0 1.5

Unemployed 177 166 74.8 18.1 3.9 2.3 0.9


Fina

ncia

l si

tuat

ion

Low 165 153

0.62

76.4 17.0 3.2 0.0 3.5

Medium 383 385 81.4 12.6 4.9 0.8 0.3

High 207 223 76.9 13.9 5.2 2.4 1.6

Futu

re b

ehav


0.00

100 0.0 0.0 0.0 0.0


Will give some vaccines 37 37 0.0 0.0 100 0.0 0.0



Table 12.4 – Future behaviour - General populationBase: Total target population


Table 12.5 – Vaccination experience - Roma population - The share of answers YES

N N u

nw

I too

k th

e ch

ild t

o th

e va

ccin

atio

n fo

llow

ing

the

cale

nder

I was

invi

ted

by p

hone

I rec

eive

d w

ritte

n no

tice

to c

ome

203 205 72.0 13.1 30.5

GenderMale 2* 2* 100 0.0 0.0

Female 201 203 71.7 13.2 30.8


More than 30 y. 52 45 84.1 13.4 33.8

Education

Primary or less 185 191 72.2 13.6 29.2

Secondary 18* 14* 69.8 7.6 43.6

Faculty 0** 0** 0.0 0.0 0.0


Rural 54 64 68.2 31.1 46.7

Region

Belgrade 38 39 100 14.0 12.5

Vojvodina 31 26 97.1 14.5 26.0

Central Serbia 134 140 58.2 12.5 36.6

Employment status

Employed 13* 11* 59.9 8.9 19.8

Unemployed 109 110 69.6 9.1 30.6


Financial situation

Low 131 133 73.1 13.8 31.0

Medium 47 48 69.7 12.0 29.5

High 21* 21* 64.2 9.4 36.2

Future behaviour

Will vaccinate 178 179 75.2 12.7 31.9



Will not vaccinate 0** 0** 0.0 0.0 0.0


271Appendices


Base: respondents whose children have been vaccinated at least one time (99% of target population)

paed

iatri

cian

info

rmed

m

e ab

out t

he n

ext

imm

uniz

atio

n

I was

n’t a

nsw

ered

m

y qu

estio

n

I was

giv

en th

e im

mun

izat

ion

cale

ndar

I wai

ted

long

er th

an

half

an h

our

ther

e w

ere

no

vacc

ines

ava

ilabl

e

child

was

exa

min

ed

befo

re v

acci

natio

n

I was

info

rmed

abo

ut th

e pu

rpos

e of

the

vacc

ine

I was

info

rmed

abo

ut

adve

rse

effe

cts

he in

form

ed u

s ho

w to

re

act t

o ad

vers

e ef

fect

s

Chi

ld h

ad a

mild

reac

tion

Chi

ld h

ad a

stro

ng

reac

tion

gene

rally

pos

itive

82.8 8.5 76.7 26.8 13.9 95.4 78.7 87.2 90.7 57.7 4.4 95.4

100 0.0 55.8 55.8 0.0 100 44.2 100 55.8 55.8 0.0 100

82.6 8.6 76.9 26.5 14.1 95.4 79.1 87.1 91.1 57.7 4.5 95.4

83.1 7.1 76.8 25.2 14.0 96.0 75.9 84.7 90.2 51.4 4.2 95.6

81.8 12.5 76.4 31.3 13.8 93.7 86.7 94.5 92.2 75.9 5.0 95.0

83.7 7.0 78.2 24.4 14.3 96.8 77.3 87.5 90.5 56.1 4.9 95.0

74.0 23.9 61.4 51.4 10.0 81.6 92.8 84.8 92.4 73.8 0.0 100

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

83.0 4.1 75.3 26.8 14.5 97.3 76.3 87.4 91.5 58.4 5.0 94.8

82.1 20.8 80.4 26.9 12.3 90.2 85.5 86.7 88.4 55.7 2.9 97.3

87.5 6.4 85.6 16.3 3.8 100 88.2 100 96.2 61.2 000 97.3

82.9 3.3 100 14.7 2.9 100 97.1 91.4 100 38.3 5.7 100

81.4 10.3 68.7 32.6 19.4 93.1 71.7 82.6 87.0 61.3 5.4 93.9

69.4 10.9 52.1 36.3 0.0 89.1 78.9 89.1 81.0 65.0 8.1 91.9

76.6 9.3 74.7 28.0 6.9 95.6 84.6 87.9 91.6 53.6 5.0 92.5

93.1 7.1 83.2 23.7 25.6 96.1 70.8 86.0 91.0 62.1 3.1 100

79.9 8.1 75.2 28.0 8.2 93.6 82.0 88.3 91.7 59.5 5.5 93.6

85.7 12.1 86.2 24.0 19.7 98.0 75.6 85.3 88.9 59.5 2.0 98.1

90.6 4.5 63.8 22.6 40.8 100 59.8 82.1 86.6 41.7 4.5 100

85.7 6.5 80.6 25.8 14.1 96.1 80.8 88.6 94.5 57.6 5.1 98.0

60.4 26.2 51.8 31.5 18.2 94.9 72.6 86.2 67.5 65.3 0.0 78.6

100 24.9 50.0 75.1 0.0 100 49.9 50.0 50.0 24.9 0.0 75.1

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0


Table 12.6 – Vaccination experience - General population - The share of answers YES



N N u

nw

I too

k th

e ch

ild t

o th

e va

ccin

atio

n fo

llow

ing

the

cale

ndar

I was

invi

ted

by p

hone

I rec

eive

d w

ritte

n no

tice

to c

ome

821 820 88.3 17.2 17.6

GenderMale 8* 9* 76.4 7.0 17.2

Female 813 811 88.4 17.4 17.6


More than 30 y. 452 462 88.5 16.5 17.7

Education

Primary or less 97 61 91.8 20.8 18.4

Secondary 482 467 88.3 18.8 18.6

Faculty 243 292 86.7 12.8 15.3


Rural 297 276 87.8 22.1 20.0

Region

Belgrade 192 213 86.7 10.9 15.4

Vojvodina 215 226 84.6 22.1 13.5

Central Serbia 414 381 90.9 17.7 20.7

Employment status

Employed 409 433 87.4 15.8 17.9

Unemployed 176 164 93.5 16.5 17.3


Financial situation

Low 164 152 91.2 17.2 16.5

Medium 381 383 89.2 17.3 17.8

High 206 222 81.6 17.7 19.6

Future behaviour

Will vaccinate 651 652 88.9 15.4 17.2




273Appendices


paed

iatri

cian

info

rmed

m

e ab

out t

he n

ext

imm

uniz

atio

n

I was

n’t a

nsw

ered

m

y qu

estio

n

I was

giv

en th

e im

mun

izat

ion

cale

ndar

I wai

ted

long

er th

an

half

an h

our

ther

e w

ere

no

vacc

ines

ava

ilabl

e

child

was

exa

min

ed

befo

re v

acci

natio

n

I was

info

rmed

abo

ut th

e pu

rpos

e of

the

vacc

ine

I was

info

rmed

abo

ut

adve

rse

effe

cts

he in

form

ed u

s ho

w to

re

act t

o ad

vers

e ef

fect

s

Chi

ld h

ad a

mild

reac

tion

Chi

ld h

ad a

stro

ng

reac

tion

gene

rally

pos

itive

86.4 16.9 78.7 21.4 14.0 95.9 76.3 78.6 81.6 42.4 3.3 89.5

100 12.0 88.9 12.0 15.7 100 81.0 93.0 100 20.3 0.0 100

86.3 16.9 78.6 21.4 13.9 95.9 76.2 78.5 81.4 42.7 3.3 89.4

84.7 16.3 78.1 23.7 10.9 96.4 74.3 79.2 82.0 41.3 3.3 89.2

87.8 17.3 79.1 19.5 16.5 95.5 78.0 78.1 81.2 43.4 3.2 89.9

90.3 15.6 81.0 17.6 16.2 95.8 84.6 87.8 91.5 28.7 0.0 92.9

86.3 17.0 82.3 20.9 10.3 96.0 77.6 80.7 81.7 44.3 3.9 89.2

85.2 17.1 70.7 23.7 20.3 95.9 70.5 70.9 77.3 44.3 3.4 89.0

86.8 19.2 76.9 24.6 15.3 95.5 74.8 76.4 80.7 44.7 4.3 88.7

85.9 12.8 81.8 15.6 11.7 96.8 78.9 82.6 83.1 38.4 1.5 91.0

83.9 24.9 70.3 23.5 15.3 94.0 69.8 70.4 75.7 43.9 6.1 86.9

90.2 11.8 76.9 22.2 15.0 96.2 78.1 80.9 83.6 46.3 2.0 90.9

85.6 15.7 83.5 19.9 12.8 96.7 78.4 81.2 83.3 39.8 2.6 90.1

85.5 16.1 78.9 21.9 14.2 94.5 74.5 78.4 79.9 44.0 3.3 91.0

87.9 22.1 83.4 24.6 19.5 99.1 80.0 84.1 86.5 46.2 6.0 86.8

87.0 14.3 74.8 17.9 9.4 96.0 76.7 74.9 80.8 37.0 1.2 89.1

86.6 22.3 76.7 26.7 14.5 92.9 77.0 74.2 80.4 44.3 5.1 88.4

86.9 15.7 79.5 18.4 14.3 97.4 80.9 84.8 84.3 39.9 1.5 92.0

85.8 17.6 80.1 20.4 12.6 94.3 70.3 75.0 79.5 47.1 4.3 87.3

88.3 12.8 80.0 19.7 12.6 96.3 79.9 82.5 84.5 40.5 2.4 93.8

83.8 21.9 76.0 26.1 17.3 96.0 69.3 69.4 73.9 45.5 3.3 81.0

75.4 48.7 69.5 29.2 24.6 91.3 51.2 45.6 58.3 60.4 2.2 62.9

50.0 75.7 100 24.3 20.2 100 25.7 61.8 86.1 29.8 29.8 56.3




Table 12.7 – Risk assessment - Roma population - % of respondents who agree or partly agree with the statement who agree or partly agree with the statement

N N u

nw

I am

worri

ed ab

out th

e sid

e effe

cts of

vacc

ines

I am

worri

ed th

at va

ccine

s ca

n trig

ger o

ther d

iseas

es

I am

worri

ed ab

out th

e mult

iple

vacc

ines i

n one

take

211 211 40.2 38.4 31.9

GenderMale 2* 2* 0.0 0.0 44.2

Female 209 209 40.6 38.9 31.8


More than 30 y. 57 48 40.0 36.4 24.4

Education

Primary or less 193 197 38.6 35.3 29.5

Secondary 18* 14* 56.7 71.2 56.8

Faculty 0** 0** 0.0 0.0 0.0


Rural 57 66 32.9 33.8 32.3

Region

Belgrade 39 40 28.1 21.2 21.8

Vojvodina 31 26 20.1 17.2 26.6

Central Serbia 140 145 48.0 48.0 35.9

Employment status

Employed 14 12 34.9 19.6 24.3

Unemployed 113 113 38.3 36.2 32.9


Financial situation

Low 139 139 36.5 34.3 29.1

Medium 47 48 41.1 35.7 33.5

High 21* 21* 67.8 59.1 45.1

Future behaviour

Will vaccinate 180 181 35.8 33.5 30.5


Will give some vaccines 4* 4* 100 75.1 49.9


275Appendices


Base: Total target populationI a

m wo

rried

that

child

ren a

re

expo

sed t

o vac

cines

too e

arly

I am

worri

ed ab

out th

e qu

ality

of the

vacc

ines

I am

worri

ed th

at my

child

can

get d

iseas

e if n

ot va

ccina

ted

I am

worri

ed ab

out th

e po

ssibl

e outb

reak

s of v

accin

e pr

even

table

disea

ses

I am

worri

ed ab

out th

e co

nseq

uenc

es of

mor

e pa

rents

refus

ing to

va

ccina

te the

ir chil

dren

All in

all th

e vac

cinati

on is

usefu

l

vacc

inatio

n sho

uld

be m

anda

tory

Ther

e sho

uld be

lega

l co

nseq

uenc

es fo

r par

ents

who

refus

e to v

accin

ate th

eir ch

ildre

n

I am

hesit

ating

to va

ccina

te my

ch

ild be

caus

e it is

man

dator

y

29.0 30.4 81.3 70.1 44.9 92.5 86.9 57.7 14.5

44.2 44.2 44.2 100 0.0 55.8 55.8 0.0 0.0

28.8 30.3 81.7 69.7 45.4 92.9 87.2 58.4 14.7

31.0 30.5 80.9 70.0 44.9 92.8 86.4 59.0 16.6

23.5 30.2 82.4 70.2 44.7 91.7 88.1 54.3 8.9

27.1 28.3 81.6 69.7 43.0 91.8 86.4 58.8 15.4

48.6 53.3 77.9 74.0 64.1 100 92.4 46.6 5.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

29.9 32.2 83.7 73.5 41.8 93.9 89.0 53.0 14.8

26.6 25.8 74.7 60.8 53.3 88.8 81.2 70.6 13.6

19.3 10.4 87.6 64.0 31.2 100 97.4 62.4 5.8

11.6 14.7 97.1 65.6 41.4 100 90.6 61.5 17.4

35.6 39.5 76.0 72.7 49.5 88.8 83.1 55.6 16.3

26.9 46.7 71.2 70.6 38.8 65.8 65.8 15.2 7.3

28.2 05.0 76.0 61.3 37.4 93.2 83.6 54.9 15.2

30.4 35.1 90.1 81.8 56.0 96.1 95.0 68.9 14.8

27.5 26.9 79.4 65.5 39.7 92.0 84.6 55.9 18.7

23.0 31.5 86.5 77.1 44.6 93.9 88.6 58.2 1.9

54.7 40.8 91.0 77.9 72.8 91.0 95.5 77.6 17.9

25.8 26.9 86.0 71.8 47.4 97.5 92.7 63.5 13.4

45.3 48.9 61.0 65.6 33.9 90.0 73.5 31.9 14.1

74.9 74.9 74.9 100 50.0 25.1 25.1 0.0 50.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0



Table 12.8 – Risk assessment – General population - % of respondents who agree or partly agree with the statement

N N u

nw

I am

worri

ed ab

out th

e sid

e effe

cts of

vacc

ines

I am

worri

ed th

at va

ccine

s ca

n trig

ger o

ther d

iseas

es

I am

worri

ed ab

out th

e mult

iple

vacc

ines i

n one

take

824 824 49.1 43.9 34.3

GenderMale 8* 9* 44.9 17.2 17.2

Female 816 815 49.2 44.2 34.5


More than 30 y. 454 465 48.5 44.8 32.3

Education

Primary or less 97 61 34.1 27.5 20.9

Secondary 483 469 50.1 46.2 37.0

Faculty 244 294 53.1 45.9 34.3


Rural 299 278 41.8 38.0 28.3

Region

Belgrade 194 215 59.7 53.4 45.5

Vojvodina 215 226 38.0 33.5 24.9

Central Serbia 415 383 50.0 44.8 34.0

Employment status

Employed 411 435 49.0 44.3 33.2

Unemployed 177 166 53.7 50.2 40.9


Financial situation

Low 165 153 52.3 46.8 39.8

Medium 383 385 47.0 40.8 32.4

High 207 223 48.5 43.9 34.5

Future behaviour

Will vaccinate 651 653 40.7 34.4 27.2



Will not vaccinate 8 8 100 100 86.2

277Appendices


Base: Total target populationI a

m wo

rried

that

child

ren a

re

expo

sed t

o vac

cines

too e

arly

I am

worri

ed ab

out th

e qu

ality

of the

vacc

ines

I am

worri

ed th

at my

child

can

get d

iseas

e if n

ot va

ccina

ted

I am

worri

ed ab

out th

e po

ssibl

e outb

reak

s of v

accin

e pr

even

table

disea

ses

I am

worri

ed ab

out th

e co

nseq

uenc

es of

mor

e pa

rents

refus

ing to

va

ccina

te the

ir chil

dren

All in

all th

e vac

cinati

on is

usefu

l

vacc

inatio

n sho

uld

be m

anda

tory

Ther

e sho

uld be

lega

l co

nseq

uenc

es fo

r par

ents

who

refus

e to v

accin

ate th

eir ch

ildre

n

I am

hesit

ating

to va

ccina

te my

ch

ild be

caus

e it is

man

dator

y

30.9 46.5 77.0 68.0 66.2 84.0 72.2 40.3 17.8

17.2 29.2 100 95.0 78.5 100 100 50.2 0.0

31.0 46.7 76.8 67.8 66.0 83.9 71.9 40.2 18.0

32.3 50.1 76.5 65.9 66.1 83.5 74.0 38.5 15.4

29.7 43.7 77.4 69.8 66.2 84.5 70.7 41.7 19.7

13.7 25.4 72.0 59.0 67.3 78.0 78.1 53.8 21.0

34.0 48.6 78.3 70.9 64.7 85.7 73.0 40.6 16.1

31.5 50.8 76.5 66.0 68.5 83.2 68.1 34.4 20.0

33.6 48.0 75.8 69.6 66.9 81.6 68.5 38.3 18.6

26.1 44.0 79.2 65.2 64.8 88.3 78.6 43.8 16.3

48.4 56.3 72.8 69.4 66.3 79.3 66.1 39.7 22.8

21.4 35.7 83.1 64.4 63.7 89.6 77.6 54.1 18.4

27.6 47.6 75.8 69.3 67.4 83.3 72.2 33.4 15.1

29.6 48.8 78.7 72.2 67.6 86.4 71.9 43.9 17.1

40.0 48.5 72.4 64.7 68.2 79.6 71.1 30.7 15.2

26.2 41.0 77.5 63.3 62.0 83.3 73.5 41.2 21.0

34.0 47.6 70.1 61.8 62.8 77.8 66.8 38.0 24.6

31.9 46.0 79.1 69.7 66.7 85.7 75.4 41.4 16.5

27.5 45.3 76.2 67.7 65.3 86.5 71.7 40.6 16.3

21.7 38.4 81.4 69.4 68.1 91.5 81.7 46.5 12.3

59.7 68.3 70.7 73.3 70.3 67.3 47.1 21.5 27.2

74.0 92.4 53.3 47.5 46.5 41.8 21.8 12.7 66.0

86.2 100 0.0 0.0 20.4 23.4 0.0 0.0 73.0


N N u

nw

Vacc

ine ag

ainst

MMR

caus

es au

tism

Pres

erva

tives

in th

e va

ccine

s are

toxic

Comb

inatio

n vac

cines

ar

e only

mar

ketin

g tric

k of

phar

macy

secto

r

211 211 4.9 6.3 7.4

GenderMale 2* 2* 0.0 0.0 44.2

Female 209 209 4.9 6.4 7.0


More than 30 y. 57 48 3.2 2.5 6.6

Education

Primary or less 193 197 3.4 6.5 6.9

Secondary 18* 14* 20.0 5.0 12.6

Faculty 0** 0** 0.0 0.0 0.0


Rural 57 66 0.9 3.3 2.4

Region

Belgrade 39 40 2.9 3.7 9.1

Vojvodina 31 26 0.0 0.0 0.0

Central Serbia 140 145 6.5 8.5 8.5

Employment status

Employed 14* 12* 0.0 0.0 14.4

Unemployed 113 113 5.0 6.1 10.0


Financial situation

Low 139 139 2.8 3.6 7.2

Medium 47 48 1.9 9.9 10.0

High 21* 21* 13.4 17.9 4.5

Future behaviour

Will vaccinate 180 181 4.2 4.6 5.2





Table 12.9 – Myths – Roma population - % of respondents who agree or partly agree with the statement

279Appendices

The v

accin

es im

porte

d in

Serb

ia ar

e of lo

wer q

uality

.

The q

uality

chec

k of

the im

porte

d vac

cines

is

not g

ood e

noug

h

It is b

etter

to w

ait fo

r the

child

to

be ol

der a

nd to

stre

ngthe

n. an

d the

n vac

cinate

it

All v

iral “r

ash”

dise

ases

ar

e ess

entia

lly ha

rmles

s

The d

iseas

es th

at ar

e ma

ndato

ry to

vacc

inate

again

st ar

e mild

dise

ases

Ther

e is n

o rea

l dan

ger o

f an

outbr

eak o

f the v

accin

e pr

even

table

disea

ses i

n Ser

bia.

Mode

rn me

dicine

can m

ore ea

sily cu

re dis

ease

s that

can b

e prev

ented

by

the va

ccine

than

it can

cure

unwa

nted

cons

eque

nces

of va

ccina

tion

Too m

any v

accin

es ar

e give

n to

the ch

ildre

n and

this

will

hamp

er m

y chil

d’s im

munit

y

It is

bette

r for

the

child

to

over

com

e th

e dis

ease

and

th

us st

reng

then

imm

unity

. ra

ther

than

bein

g va

ccina

ted

Only

the fir

st do

se of

vacc

ine

is im

porta

nt. ot

her d

oses

(re-

vacc

inatio

n) ar

e opti

onal

13.6 20.2 26.6 19.0 10.4 35.7 39.7 24.7 15.8 6.5

44.2 44.2 44.2 0.0 44.2 0.0 100 100 44.2 0.0

13.2 20.0 26.4 19.2 10.1 36.1 39.0 23.8 15.5 6.5

15.0 18.6 27.8 19.7 9.8 34.0 38.6 23.9 16.7 5.6

9.7 24.7 23.5 17.1 12.2 40.5 42.6 26.7 13.5 8.7

12.4 18.7 26.0 16.9 9.9 33.0 36.9 23.1 14.9 7.1

26.0 36.0 33.6 40.8 15.8 64.7 69.0 41.2 26.0 0.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

13.6 22.2 27.6 22.5 13.0 35.7 37.6 27.1 14.1 6.9

13.4 14.9 24.2 9.4 3.5 35.8 45.5 18.0 20.4 5.2

6.2 15.3 24.3 13.1 8.0 51.0 45.0 20.5 10.8 0.0

6.2 14.4 14.4 5.7 0.0 31.0 12.0 9.0 0.0 8.6

17.3 22.9 30.0 23.6 13.4 32.5 44.4 29.3 20.8 7.8

7.3 14.6 44.0 17.1 7.3 39.0 55.9 33.6 34.2 7.3

17.4 21.3 26.8 21.1 8.6 39.0 36.5 25.4 19.1 6.3

9.5 19.8 23.5 16.4 13.5 30.8 41.3 22.2 8.3 6.5

13.1 21.3 28.2 13.8 7.5 28.2 36.7 24.6 20.0 9.1

12.1 15.8 26.1 22.9 14.9 53.3 52.0 22.3 4.2 2.0

23.4 27.4 22.9 31.7 22.4 37.0 40.7 31.7 17.9 0.0

10.7 19.3 24.5 19.4 11.7 38.7 41.6 20.6 11.8 6.7

29.1 26.8 33.9 4.7 5.3 24.8 41.2 36.1 19.4 8.1

74.9 50.0 50.0 25.1 0.0 25.1 25.1 74.9 49.9 0.0

0.0 0.0 41.2 58.8 0.0 0.0 0.0 58.8 100 0.0



N N u

nw

Vacc

ine ag

ainst

MMR

caus

es au

tism

Pres

erva

tives

in th

e va

ccine

s are

toxic

Comb

inatio

n vac

cines

ar

e only

mar

ketin

g tric

k of

phar

macy

secto

r

824 824 15.1 18.1 26.3

GenderMale 8* 9* 17.2 0.0 0.0

Female 816 815 15.0 18.3 26.5


More than 30 y. 454 465 16.1 18.6 23.6

Education

Primary or less 97 61 8.3 12.9 23.1

Secondary 483 469 15.5 16.5 27.6

Faculty 244 294 16.9 23.4 24.8


Rural 299 278 10.1 14.6 26.0

Region

Belgrade 194 215 21.5 26.5 34.7

Vojvodina 215 226 12.0 14.2 19.5

Central Serbia 415 383 13.6 16.3 25.8

Employment status

Employed 411 435 16.1 17.9 23.6

Unemployed 177 166 17.0 20.8 31.5


Financial situation

Low 165 153 14.1 19.3 28.7

Medium 383 385 13.8 18.6 27.2

High 207 223 15.1 16.0 22.4

Future behaviour

Will vaccinate 651 653 8.9 12.1 19.2





Table 12.10 – Myths – General population - % of respondents who agree or partly agree with the statement

281Appendices

The v

accin

es im

porte

d in

Serb

ia ar

e of lo

wer q

uality

.

The q

uality

chec

k of

the im

porte

d vac

cines

is

not g

ood e

noug

h

It is b

etter

to w

ait fo

r the

child

to

be ol

der a

nd to

stre

ngthe

n. an

d the

n vac

cinate

it

All v

iral “r

ash”

dise

ases

ar

e ess

entia

lly ha

rmles

s

The d

iseas

es th

at ar

e ma

ndato

ry to

vacc

inate

again

st ar

e mild

dise

ases

Ther

e is n

o rea

l dan

ger o

f an

outbr

eak o

f the v

accin

e pr

even

table

disea

ses i

n Ser

bia.

Mode

rn me

dicine

can m

ore ea

sily cu

re dis

ease

s that

can b

e prev

ented

by

the va

ccine

than

it can

cure

unwa

nted

cons

eque

nces

of va

ccina

tion

Too m

any v

accin

es ar

e give

n to

the ch

ildre

n and

this

will

hamp

er m

y chil

d’s im

munit

y

It is

bette

r for

the

child

to

over

com

e th

e dis

ease

and

th

us st

reng

then

imm

unity

. ra

ther

than

bein

g va

ccina

ted

Only

the fir

st do

se of

vacc

ine

is im

porta

nt. ot

her d

oses

(re-

vacc

inatio

n) ar

e opti

onal

32.0 33.3 27.2 14.7 11.6 19.0 30.1 25.9 16.0 9.9

0.0 12.0 17.2 0.0 0.0 15.7 52.0 17.2 0.0 0.0

32.4 33.5 27.3 14.9 11.7 19.0 29.9 25.9 16.2 10.0

33.0 33.2 26.2 15.6 10.3 20.4 32.1 23.6 13.9 10.7

31.3 33.4 28.0 14.1 12.6 17.8 28.5 27.7 17.7 9.2

24.0 19.3 15.3 15.5 13.0 30.5 18.4 14.6 9.7 8.0

32.6 34.0 27.3 14.7 12.1 17.3 32.1 27.2 17.5 11.6

34.1 37.3 31.7 14.4 10.1 17.6 30.9 27.6 15.5 7.3

32.7 35.0 29.4 15.0 11.2 17.4 29.2 28.8 15.6 10.5

31.0 30.3 23.4 14.3 12.4 21.7 31.7 20.6 16.8 8.8

41.1 45.8 39.5 10.2 15.9 20.4 38.7 36.2 26.8 11.9

25.0 26.4 16.3 14.9 6.8 18.0 21.8 16.8 13.3 7.3

31.5 31.0 27.1 16.8 12.1 18.9 30.4 25.8 12.3 10.3

32.2 33.2 28.1 13.6 8.9 16.1 30.4 26.8 16.0 9.4

34.9 33.3 31.5 19.1 20.9 26.1 35.3 28.6 19.2 10.8

29.6 33.4 22.4 13.4 9.3 18.6 25.7 22.1 13.6 10.1

35.9 38.4 24.4 13.0 10.3 19.8 31.0 24.9 13.9 11.4

31.6 31.2 29.1 13.5 12.5 18.1 34.0 25.3 15.4 9.8

28.4 33.3 26.2 17.8 11.2 18.4 23.1 26.8 18.0 7.9

25.0 24.7 17.0 11.5 8.3 16.8 26.9 17.4 10.6 7.7

50.3 57.3 64.2 19.1 18.2 24.7 41.2 49.6 25.0 16.2

68.6 78.5 71.5 42.0 35.6 31.1 49.1 73.0 54.9 22.3

100 100 79.4 65.2 51.4 49.2 61.5 86.2 78.1 17.6



N N u

nw

TV New

spap

ers.

prin

t med

ia

Rad

io

Offi

cial

Inte

rnet

site

s

Foru

ms.

blo

gs

Soci

al m

edia

Hea

lth p

rovi

ders

Frie

nds.

fam

ily m

embe

rs.

othe

r par

ents

211 211 21.5 01.5 1.1 7.0 3.4 6.0 71.3 43.1

Gen

der Male 2* 2* 44.2 0.0 0.0 44.2 0.0 0.0 55.8 0.0

Female 209 209 21.3 1.5 1.1 6.6 3.4 6.1 71.5 43.6

Age

cate

gory Up to 30 y. 154 163 18.9 1.2 1.6 6.7 1.5 5.2 71.4 42.7

More than 30 y. 57 48 28.8 2.3 0.0 7.9 8.4 8.4 71.1 44.3

Educ

atio

n Primary or less 193 197 19.9 1.2 1.2 5.4 2.6 5.6 71.2 44.7

Secondary 18* 14* 39.1 5.5 0.0 24.3 11.2 11.2 72.4 26.2

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 19.4 2.1 0.7 7.1 3.0 6.7 74.2 42.0

Rural 57 66 27.2 0.0 2.4 6.9 4.4 4.4 63.7 46.3

Reg

ion

Belgrade 39 40 19.6 2.6 2.6 8.8 3.7 8.8 50.8 47.5

Vojvodina 31 26 3.3 0.0 0.0 6.5 6.5 6.5 79.7 59.7

Central Serbia 140 145 26.1 1.6 1.0 6.6 2.6 5.2 75.2 38.2

Empl

oym

ent

stat

us

Employed 14* 12* 15.3 0.0 7.1 21.7 14.4 14.4 56.2 49.3

Unemployed 113 113 23.9 1.7 1.2 7.4 2.1 4.6 65.4 35.8


Fina

ncia

l si

tuat

ion

Low 139 139 24.1 1.7 1.7 3.7 1.9 3.3 66.5 38.4

Medium 47 48 23.5 2.0 0.0 18.6 7.4 13.4 81.9 48.5

High 21* 21* 4.5 0.0 0.0 4.5 4.5 8.9 86.6 63.8

Futu

re b

ehav






Table 12.11 – Sources of information about health related issues – Roma population - % of respondents who get informed about health-related issues (OFTEN+ALWAYS)


283Appendices

N N u

nw

TV New

spap

ers.

prin

t med

ia

Rad

io

Offi

cial

Inte

rnet

site

s

Foru

ms.

blo

gs

Soci

al m

edia

Hea

lth p

rovi

ders

Frie

nds.

fam

ily m

embe

rs.

othe

r par

ents

824 824 21.6 12.1 3.2 26.0 17.7 18.7 67.4 61.1

Gen

der Male 8* 9* 3.6 0.0 0.0 20.3 20.3 32.3 95.0 60.6

Female 816 815 21.8 12.2 3.3 26.1 17.6 18.5 67.1 61.1

Age

cate

gory Up to 30 y. 370 359 21.0 10.7 3.9 28.1 18.9 19.3 67.9 60.5

More than 30 y. 454 465 22.1 13.3 2.7 24.3 16.6 18.2 66.9 61.7

Educ

atio

n Primary or less 97 61 22.9 5.6 1.1 18.8 6.6 7.1 59.4 54.1

Secondary 483 469 20.6 10.6 3.0 22.3 15.6 18.2 70.0 62.0

Faculty 244 294 23.0 17.6 4.7 36.4 26.1 24.1 65.3 62.1

Type

of

settl

emen

t

Urban 525 546 22.6 14.8 3.6 28.1 18.3 18.6 63.7 60.0

Rural 299 278 19.7 7.3 2.6 22.4 16.6 18.7 73.8 63.0

Reg

ion

Belgrade 194 215 26.0 21.1 4.9 31.3 22.0 21.1 71.1 64.6

Vojvodina 215 226 16.8 7.3 2.5 25.8 16.4 14.5 64.9 55.4

Central Serbia 415 383 22.0 10.4 2.9 23.7 16.3 19.7 66.8 62.4

Empl

oym

ent

stat

us

Employed 411 435 21.0 14.4 4.9 26.1 15.9 19.5 69.4 63.2

Unemployed 177 166 25.7 10.8 2.2 22.6 18.8 20.7 66.3 64.3


Fina

ncia

l si

tuat

ion

Low 165 153 22.7 14.9 2.5 20.1 14.9 16.1 64.6 60.5

Medium 383 385 20.9 9.7 3.2 27.4 17.6 18.4 69.4 62.2

High 207 223 24.4 14.3 3.8 29.1 21.1 19.9 62.6 58.8

Futu

re b

ehav




Will not vaccinate 8* 8* 16.6 25.2 0.0 20.6 17.6 40.6 43.7 100


Table 12.12 – Sources of information about health related issues- % of respondents who get informed about health-related issues (OFTEN+ALWAYS)



N N u

nw

Do yo

u kno

w ho

w va

ccina

tion

prote

cts ag

ainst

disea

se?

Some

grou

ps of

child

ren

shou

ld NO

T be

immu

nized

. W

hat g

roup

s are

thos

e

Do yo

u kno

w ag

ainst

which

dis

ease

is B

CG va

ccine

?

Do yo

u kno

w ag

ainst

which

dis

ease

s is M

MR va

ccine

?

Do yo

u kno

w ag

ainst

which

dis

ease

s DiTe

Per v

accin

e?

Do yo

u kno

w wh

at the

best

timeli

ne fo

r the

vacc

inatio

n is?

Do yo

u kno

w wh

at re

vacc

inatio

n is?

All a

nswe

rs ar

e cor

rect

in G

secti

on

211 211 16.8 0.5 22.2 1.0 0.7 25.5 29.2 0.0

Gen

der Male 2* 2* 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Female 209 209 17.0 0.5 22.4 1.0 0.8 25.8 29.5 0.0

Age

cate

gory Up to 30 y. 154 163 13.7 0.7 19.2 0.7 0.7 26.1 25.2 0.0

More than 30 y. 57 48 25.4 0.0 30.4 2.0 1.0 24.1 40.2 0.0

Educ

atio

n Primary or less 193 197 16.7 0.5 19.5 1.1 0.8 23.0 25.6 0.0

Secondary 18* 14* 18.2 0.0 50.3 0.0 0.0 52.1 67.2 0.0

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 15.9 0.7 20.0 01.4 0.7 18.6 24.9 0.0

Rural 57 66 19.2 0.0 28.0 0.0 1.0 44.2 40.9 0.0

Reg

ion

Belgrade 39 40 17.9 2.6 26.6 5.5 4.0 36.2 53.1 0.0

Vojvodina 31 26 9.8 0.0 15.6 0.0 0.0 30.4 24.5 0.0

Central Serbia 140 145 18.1 0.0 22.4 0.0 0.0 21.5 23.6 0.0

Empl

oym

ent

stat

us

Employed 14 12 22.5 0.0 66.4 0.0 7.1 22.4 49.3 0.0

Unemployed 113 113 11.5 0.0 17.6 1.9 0.5 25.3 29.1 0.0


Fina

ncia

l si

tuat

ion

Low 139 139 13.7 0.0 19.9 1.5 01.1 24.0 26.0 0.0

Medium 47 48 23.3 2.1 32.7 0.0 0.0 33.8 40.1 0.0

High 21* 21* 26.8 0.0 18.3 0.0 0.0 9.4 18.9 0.0

Futu

re b

ehav






Base: Total target populationTable 12.13 – Knowledge about immunization – Roma population - the share of correct responses

285Appendices

N N u

nw

Do yo

u kno

w ho

w va

ccina

tion

prote

cts ag

ainst

disea

se?

Some

grou

ps of

child

ren

shou

ld NO

T be

immu

nized

. W

hat g

roup

s are

thos

e

Do yo

u kno

w ag

ainst

which

dis

ease

is B

CG va

ccine

?

Do yo

u kno

w ag

ainst

which

dis

ease

s is M

MR va

ccine

?

Do yo

u kno

w ag

ainst

which

dis

ease

s DiTe

Per v

accin

e?

Do yo

u kno

w wh

at the

best

timeli

ne fo

r the

vacc

inatio

n is?

Do yo

u kno

w wh

at re

vacc

inatio

n is?

All a

nswe

rs ar

e cor

rect

in G

secti

on

824 824 32.5 1.6 58.7 24.2 16.2 49.9 67.8 1.4

Gen

der Male 8* 9* 51.4 0.0 48.4 9.7 5.0 70.6 65.0 0.0

Female 816 815 32.3 1.6 58.9 24.4 16.4 49.6 67.8 1.4

Age

cate

gory Up to 30 y. 370 359 28.1 1.9 54.7 21.9 15.0 48.6 66.7 1.2

More than 30 y. 454 465 36.0 1.4 62.0 26.1 17.3 50.9 68.6 1.5

Educ

atio

n Primary or less 97 61 6.8 0.0 35.9 9.7 3.9 40.2 43.9 0.0

Secondary 483 469 27.0 2.2 55.7 19.2 12.9 51.3 66.9 0.7

Faculty 244 294 53.5 1.2 73.8 39.8 27.8 50.9 78.9 3.3

Type

of

settl

emen

t

Urban 525 546 39.5 1.9 65.6 31.3 20.5 48.5 69.9 1.8

Rural 299 278 20.1 1.2 46.7 11.7 8.8 52.3 64.0 0.6

Reg

ion

Belgrade 194 215 43.4 1.4 76.5 30.5 21.4 45.6 76.7 1.9

Vojvodina 215 226 37.7 0.8 63.1 26.7 18.7 58.8 73.2 2.3

Central Serbia 415 383 24.7 2.1 48.2 20.0 12.6 47.2 60.8 0.7

Empl

oym

ent

stat

us

Employed 411 435 36.7 1.4 64.1 26.0 18.6 49.8 70.2 1.3

Unemployed 177 166 28.9 0.8 52.7 21.1 11.6 51.1 62.8 1.9


Fina

ncia

l si

tuat

ion

Low 165 153 23.8 1.9 50.4 17.4 10.5 44.2 56.3 1.7

Medium 383 385 34.6 2.2 60.5 28.8 18.3 51.8 68.9 1.6

High 207 223 39.1 1.0 66.3 28.1 17.2 49.3 74.9 1.0

Futu

re b

ehav






Base: Total target populationTable 1214 – Knowledge about immunization - the share of correct responses


N N u

nw

Fami

ly

Clos

e frie

nds

Healt

h pro

vider

s

Othe

r par

ents

Media

My re

ligiou

s beli

efs

Roma

comm

unity

lead

ers

211 211 90.9 81.7 94.7 70.3 60.8 76.2 50.4

Gen

der Male 2* 2* 100 100 100 0.0 44.2 55.8 0.0

Female 209 209 90.8 81.5 94.6 71.0 61.0 76.4 51.0

Age

cate

gory Up to 30 y. 154 163 91.3 82.8 94.0 74.4 58.3 73.2 50.0

More than 30 y. 57 48 89.9 78.8 96.5 58.9 67.7 84.1 51.5

Educ

atio

n Primary or less 193 197 90.1 80.7 95.6 69.9 61.4 76.8 49.8

Secondary 18 14 100 92.4 85.1 74.4 55.1 69.9 56.3

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 91.0 82.7 96.4 73.8 64.0 76.8 43.3

Rural 57 66 90.8 79.1 90.0 60.5 52.1 74.5 69.6

Reg

ion

Belgrade 39 40 96.3 94.5 100 88.0 77.1 100 34.9

Vojvodina 31 26 100 100 100 97.1 64.1 65.7 65.0

Central Serbia 140 145 87.4 74.1 92.0 59.3 55.5 71.9 51.4

Empl

oym

ent

stat

us

Employed 14* 12* 73.1 71.2 80.4 48.6 61.3 73.1 48.6

Unemployed 113 113 93.4 80.5 94.6 70.2 56.3 67.6 37.0

Housewife/Pensioner/Student 84 86 90.7 85.2 97.3 74.1 66.9 88.3 68.8

Fina

ncia

l si

tuat

ion

Low 139 139 89.6 77.9 95.2 67.3 61.0 72.8 45.9

Medium 47 48 96.1 93.2 98.0 73.0 63.1 91.0 53.4

High 21* 21* 86.6 77.2 95.5 77.2 59.3 73.4 63.0

Futu

re b

ehav

iour Will vaccinate 180 181 98.1 87.6 96.9 76.6 63.6 82.2 54.8

Probably will vaccinate 20* 20* 73.9 71.2 100 53.1 61.6 66.1 39.4

Will give some vaccines 4* 4* 0.0 0.0 74.9 0.0 50.0 0.0 0.0

Will not vaccinate 3* 2* 0.0 0.0 0.0 0.0 0.0 0.0 0.0

*: N<25. data is not analysed. **: No data.


Table 12.15 – Support of the surrounding – Roma population - the share of those who support somewhat and completely

287Appendices

N N u

nw

Fami

ly

Clos

e frie

nds

Healt

h pro

vider

s

Othe

r par

ents

Media

My re

ligiou

s beli

efs

824 824 80.3 69.8 89.5 57.9 45.8 54.8

Gen

der Male 8* 9* 95.0 95.0 100 84.0 79.1 66.7

Female 816 815 80.2 69.6 89.4 57.6 45.5 54.7

Age

cate

gory Up to 30 y. 370 359 78.7 65.7 87.5 54.8 38.3 54.5

More than 30 y. 454 465 81.6 73.1 91.2 60.5 52.0 55.1

Educ

atio

n Primary or less 97 61 79.2 65.4 91.0 57.7 45.8 64.1

Secondary 483 469 80.7 70.9 89.8 57.7 45.6 57.7

Faculty 244 294 80.1 69.5 88.5 58.3 46.4 45.6

Type

of

settl

emen

t

Urban 525 546 76.8 66.4 89.0 52.4 44.0 49.0

Rural 299 278 86.6 75.7 90.6 67.6 49.1 65.1

Reg

ion

Belgrade 194 215 74.0 65.1 89.9 53.6 54.8 52.8

Vojvodina 215 226 87.8 81.3 93.7 64.3 57.8 57.9

Central Serbia 415 383 79.4 66.1 87.3 56.6 35.5 54.2

Empl

oym

ent

stat

us

Employed 411 435 80.6 72.5 90.4 55.9 47.6 55.4

Unemployed 177 166 76.5 65.5 90.0 58.5 43.0 52.8

Housewife/Pensioner/Student 236 223 82.7 68.4 87.8 61.0 44.9 55.5

Fina

ncia

l si

tuat

ion

Low 165 153 77.2 65.8 84.8 54.8 49.4 48.2

Medium 383 385 83.0 70.5 92.9 61.4 43.9 57.5

High 207 223 78.3 71.6 88.6 59.6 48.8 53.6

Futu

re b

ehav

iour Will vaccinate 651 653 89.1 78.3 92.4 64.4 46.1 62.7

Probably will vaccinate 113 111 64.5 52.2 84.0 40.6 42.3 29.1

Will give some vaccines 37 37 16.0 12.6 76.5 19.1 58.4 13.4


*: N<25. data is not analysed.


Table 12.16 – Support of the surrounding – General population - the share of those who support somewhat and completely


N N u

nw

I think

that

many

very

impo

rtant

thing

s hap

pen i

n the

wor

ld. w

hich t

he pu

blic

is ne

ver in

forme

d abo

utI th

ink th

at po

liticia

ns us

ually

do

not te

ll us t

he tr

ue

motiv

es fo

r the

ir dec

ision

s

I think

that

gove

rnme

nt ag

encie

s clo

sely

monit

or al

l citiz

ens.

I think

that

even

ts wh

ich

supe

rficial

ly se

em to

lack

a c

onne

ction

are o

ften t

he

resu

lt of s

ecre

t acti

vities

.I th

ink th

at the

re ar

e sec

ret

orga

nizati

ons t

hat g

reatl

y inf

luenc

e poli

tical

decis

ions.

211 211 67.5 63.9 36.1 39.1 42.5

Gen

der Male 2* 2* 100 0.0 44.2 44.2 44.2

Female 209 209 67.1 64.6 36.0 39.1 42.4

Age

cate

gory Up to 30 y. 154 163 64.4 62.5 40.4 39.7 42.1

More than 30 y. 57 48 76.0 67.7 24.2 37.6 43.3

Educ

atio

n Primary or less 193 197 67.3 62.8 35.9 37.0 41.1

Secondary 18 14 69.4 75.2 37.8 61.5 56.5

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 68.0 62.7 38.9 39.2 43.5

Rural 57 66 66.1 67.2 28.4 38.9 39.6

Reg

ion

Belgrade 39 40 67.3 64.9 23.4 25.9 28.3

Vojvodina 31 26 70.9 73.8 48.8 47.1 59.0

Central Serbia 140 145 66.8 61.4 36.8 41.0 42.7

Empl

oym

ent

stat

us

Employed 14 12 73.2 54.0 17.1 36.9 46.1

Unemployed 113 113 61.8 61.5 32.7 31.0 35.0


Fina

ncia

l si

tuat

ion

Low 139 139 65.0 68.5 31.0 38.8 43.6

Medium 47 48 77.0 48.7 40.5 31.4 30.5

High 21 21 77.6 63.8 63.4 54.5 58.5

Futu

re b

ehav



Will give some vaccines 4* 4* 74.9 74.9 0.0 24.9 50.0



Base: Total target populationTable 12.17 – Theories of conspiracy – Roma population - percentage YES (The sum of scores from 7 to 11)

289Appendices

N N u

nw

I think

that

many

very

impo

rtant

thing

s hap

pen i

n the

wor

ld. w

hich t

he pu

blic

is ne

ver in

forme

d abo

utI th

ink th

at po

liticia

ns us

ually

do

not te

ll us t

he tr

ue

motiv

es fo

r the

ir dec

ision

s

I think

that

gove

rnme

nt ag

encie

s clo

sely

monit

or al

l citiz

ens.

I think

that

even

ts wh

ich

supe

rficial

ly se

em to

lack

a c

onne

ction

are o

ften t

he

resu

lt of s

ecre

t acti

vities

.I th

ink th

at the

re ar

e sec

ret

orga

nizati

ons t

hat g

reatl

y inf

luenc

e poli

tical

decis

ions.

824 824 71.3 76.5 44.5 48.2 63.9

Gen

der Male 8* 9* 100 95.0 79.4 68.1 68.1

Female 816 815 71.0 76.3 44.2 47.9 63.9

Age

cate

gory Up to 30 y. 370 359 71.5 74.6 43.2 47.4 61.2

More than 30 y. 454 465 71.1 78.0 45.6 48.8 66.2

Educ

atio

n Primary or less 97 61 57.6 61.2 33.1 40.8 46.4

Secondary 483 469 71.6 78.1 44.1 47.3 63.5

Faculty 244 294 75.9 79.4 49.9 52.7 71.6

Type

of

settl

emen

t

Urban 525 546 72.3 78.8 44.9 50.7 65.6

Rural 299 278 69.4 72.5 44.0 43.6 61.0

Reg

ion

Belgrade 194 215 79.7 86.8 58.5 59.7 74.7

Vojvodina 215 226 69.5 78.2 42.0 45.3 58.4

Central Serbia 415 383 68.2 70.9 39.4 44.3 61.8

Empl

oym

ent

stat

us

Employed 411 435 72.7 78.3 45.4 51.5 66.4

Unemployed 177 166 69.8 72.1 42.6 45.2 63.7


Fina

ncia

l si

tuat

ion

Low 165 153 73.1 78.3 42.3 49.7 67.3

Medium 383 385 71.3 75.4 44.4 49.1 62.3

High 207 223 73.2 80.7 48.2 50.7 68.2

Futu

re b

ehav


Probably will vaccinate 113 111 73.0 79.8 52.8 48.6 73.6

Will give some vaccines 37 37 92.8 88.9 52.1 62.0 63.6

Will not vaccinate 8* 8* 100 83.4 69.8 100 83.4

*: N<25. data is not analysed.

Base: Total target populationTable 12.18 – Theories of conspiracy - General population - percentage YES (The sum of scores from 7 to 11)


Tables 12.9., 12.10.

Although we did not register radical differences in endorsing vaccine-related myths, once again they were more endorsed by higher educated parents and parents from Belgrade.

The group of hesitant parents who will give only some vaccines to their children agreed with a number of myths, among which that MMR causes autism (57.4%) and that preservatives in vaccines are toxic (57.6%), and even “All measles are harmless” (42%), and “Medicine can more easily cure vaccine preventable diseases than it can cure adverse vaccination re-actions” (49%).

Tables 12.11.,12.12.

There are no striking demographic differences when it comes to media use for health-relat-ed issues. Higher educated parents from general population use official Internet sites and forums/blogs more.

Parents who claim they will probably vaccinate their children use print media, official Internet sites and social media more than parents who claim they will surely vaccinate.

Tables 12.15., 12.16.

Majority of respondents claim that both their narrow social circle (family and close friends), media and health providers support vaccination, with no radical demographic differences (support is higher in Vojvodina than in Central Serbia and in rural than in urban settlements).

However, there are differences in perceived support between vaccine supporters and hesi-tant parents. As expected, the more hesitant parents are about future vaccination, less sup-port for vaccination they report from family, friends and other parents. We cannot speak of causality in this case – it can be that hesitant parents impact their surroundings, just that it can be that they are impacted by their surroundings; most probably, it is two-way interaction.

Tables 12.17.,12.18.

No differences have been registered in endorsing conspiracy theories in general, especially in Roma population. No specific socioeconomic group of Roma population has been more prone to conspiracy theories.

In general population. some conspiracy theories were less endorsed by lower educated parents (like: I think that there are secret organizations that greatly influence political deci-sions) and more by parents from Belgrade (conspiracy theories such as: I think that gov-ernment agencies closely monitor all citizens. I think that events which superficially seem to lack a connection are often the result of secret activities).

There were no statistical differences in believing in general conspiracy theories among those parents that support or or were hesitant toward vaccination.

Mostly endorsed conspiracy theories in both populations were that public is not informed about the important things in the world. and that politicians usually do not tell us the true mo-tives for their decisions. Those two conspiracy theories were endorsed by more than 70% of general population. and more than 60% of Roma population.

291Appendices

N N u

nw

Docto

rs or

nurse

s wer

e ru

de to

me o

r my c

hild

Docto

rs or

nurse

s refu

sed

to tre

at my

child

.

I was

left t

o wait

long

er

than t

he ot

hers.

I was

spok

en to

in a

mann

er

that I

did no

t und

ersta

nd.

I was

told

by do

ctors

or nu

rses

that I

am no

t a go

od pa

rent.

211 211 28.3 4.8 34.6 21.9 6.9

Gen

der Male 2* 2* 0.0 0.0 0.0 0.0 0.0

Female 209 209 28.6 4.9 35.0 22.2 7.0

Age

cate

gory Up to 30 y. 154 163 28.3 5.7 33.2 22.2 6.9

More than 30 y. 57 48 28.3 2.5 38.5 21.3 6.9

Educ

atio

n Primary or less 193 197 30.3 5.3 34.7 23.5 7.6

Secondary 18 14 7.6 0.0 33.6 5.0 0.0

Faculty 0** 0** 0.0 0.0 0.0 0.0 0.0

Type

of

settl

emen

t

Urban 154 145 30.8 5.7 35.2 23.7 5.7

Rural 57 66 21.5 2.5 33.2 17.0 10.1

Reg

ion

Belgrade 39 40 21.4 5.0 27.6 18.6 6.2

Vojvodina 31 26 11.4 5.7 17.1 25.8 0.0

Central Serbia 140 145 34.0 4.6 40.5 22.0 8.7

Empl

oym

ent

stat

us

Employed 14* 12* 26.1 0.0 16.3 0.0 26.7

Unemployed 113 113 23.6 6.9 36.4 15.5 7.1


Fina

ncia

l si

tuat

ion

Low 139 139 31.0 3.7 39.8 24.3 9.9

Medium 47 48 17.7 3.0 28.2 13.0 2.0

High 21* 21* 40.4 13.2 17.6 22.1 0.0

Futu

re b

ehav



Will give some vaccines 4* 4* 100 25.1 24.9 50.0 50.0

Will not vaccinate 3* 2* 58.8 0.0 58.8 0.0 100


Base: respondents of Roma population (20% of target population)Table 12.19 – Problems – Roma population - percentage YES


Table 12.20 – Experiences with the youngest child – percentage YES

N N u

nw

My

child

has

a m

edic

al ID

It w

as (i

s) d

iffic

ult t

o ge

t m

edic

al ID

s fo

r my

child

211 211 93.4 21.7

GenderMale 2* 2* 100 44.2

Female 209 209 93.4 21.5

Age categoryUp to 30 y. 154 163 92.8 18.8

More than 30 y. 57 48 95.2 29.5

Education

Primary or less 193 197 93.3 21.1

Secondary 18* 14* 95.0 28.4

Faculty 0** 0** 0.0 0.0

Type of settlementUrban 154 145 94.0 20.9

Rural 57 66 91.8 23.8

Region

Belgrade 39 40 95.0 11.2

Vojvodina 31 26 97.1 11.5

Central Serbia 140 145 92.2 26.9

Employment status

Employed 14 12 90.2 26.4

Unemployed 113 113 94.7 21.7

Housewife/Pensioner/Student 84 86 92.3 21.0

Financial situation

Low 139 139 95.3 23.2

Medium 47 48 92.2 17.2

High 21* 21* 82.1 26.9

Future behaviour

Will vaccinate 180 181 94.4 18.0

Probably will vaccinate 20* 20* 92.6 40.2

Will give some vaccines 4* 4* 74.9 25.1

Will not vaccinate 3* 2* 58.8 58.8


293Appendices

Base: respondents of Roma population (20% of target population)

I cou

ld no

t get

the ch

ild

vacc

inated

on tim

e be

caus

e I ha

d no o

ne to

lea

ve ot

her c

hildr

en.

I cou

ld no

t get

the ch

ild

vacc

inated

on tim

e bec

ause

I w

asn’t

sure

wha

t I wa

s su

ppos

ed to

do an

d whe

n

I cou

ld no

t get

the ch

ild

vacc

inated

on tim

e bec

ause

I fo

rgot

abou

t it.

I cou

ld no

t get

the ch

ild

vacc

inated

on tim

e bec

ause

the

med

ical c

are c

entre

is ha

rd

for m

e to r

each

(too

far).

I cou

ld no

t get

the ch

ild

vacc

inated

on tim

e bec

ause

the

re w

as no

one t

o acc

ompa

ny

me to

the h

ealth

centr

e.

I cou

ld no

t get

the ch

ild

vacc

inated

on tim

e bec

ause

tra

nspo

rt to

the he

alth c

are

centr

e is t

oo ex

pens

ive fo

r me.

I cou

ld no

t vac

cinate

the

child

on tim

e bec

ause

the

child

did n

ot ha

ve a

medic

al. he

alth r

ecor

d (or

ha

d no c

hose

n doc

tor).

4.5 10.0 6.8 4.2 4.5 4.5 7.1

0.0 0.0 0.0 0.0 0.0 0.0 0.0

4.5 10.2 6.9 4.2 4.6 4.6 7.2

2.7 9.8 6.4 2.1 3.6 3.6 6.9

9.2 10.8 7.8 9.7 6.9 6.9 7.6

4.9 10.5 7.4 4.6 4.9 4.9 6.6

0.0 5.5 0.0 0.0 0.0 0.0 12.6

0.0 0.0 0.0 0.0 0.0 0.0 0.0

3.6 8.9 6.5 0.9 2.1 2.1 7.2

6.9 13.3 7.6 12.9 10.9 10.9 6.9

3.7 12.4 8.8 3.7 3.7 3.7 7.5

0.0 0.0 0.0 0.0 0.0 0.0 5.7

5.7 11.6 7.7 5.2 5.7 5.7 7.3

0.0 28.8 9.8 19.6 19.6 19.6 9.8

4.3 10.7 3.1 3.4 4.3 3.8 6.6

5.4 6.0 11.3 2.5 2.2 2.8 7.4

6.1 13.6 7.9 6.3 6.8 6.8 7.1

2.0 4.9 7.0 0.0 0.0 0.0 6.9

0.0 0.0 0.0 0.0 0.0 0.0 9.0

2.6 6.2 3.5 2.0 1.8 1.9 6.2

7.4 22.1 19.1 2.4 7.4 7.1 19.2

0.0 25.1 25.1 0.0 0.0 0.0 0.0

58.8 100 58.8 100 100 100 0.0


Tables 12.19.,12.20.

Roma population did not report to the great extend that medical staff behaved inadequate-ly to them.

Somewhat more parents that were not employed reported that they have been spoken to in a manner that they did not understand. No other socio-demographic group experienced more unpleasant behaviour of doctors and nurses.

Roma population did not report to the great extend about different barriers to vaccination. Almost all of mentioned barriers to vaccination were reported by less than 10% of Roma parents.

Almost all Roma children have medical ID, although about 21.7% reported that it was not easy to get one. The greatest barrier to Roma parents (10.0%) regarding vaccination is to follow the schedule (vaccination calendar time frame), with no statistical differences among different socio-demographic groups. Parents from urban areas reported less about the dif-ficulties to reach the medical health centre.

...advocacy campaigns and social mobilization to support immunization. The findings from this study...

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