Determinants of Vaccine Hesitancy and Effectiveness of Vaccination Counseling Interventions among a Sample of the General Population in Palermo, Italy

"The findings in this study can be useful in constructing a tailored strategy to manage vaccine-hesitant parents by establishing a positive dialogue, providing education targeting their concerns, maintaining a relationship with these families, and making every effort to follow the recommended immunization schedule."

Recent declines in vaccination coverage in Italy have been associated with the dissemination of incorrect information in the mass media and social media. Health authorities and the medical community have recognised vaccination counseling as a tool for counteracting vaccination hesitancy and for increasing health advocacy among the general population. Conducted in the province of Palermo, Italy, this cross-sectional study sought to evaluate people's knowledge, attitudes, and behaviours regarding vaccination issues, to estimate the prevalence of vaccine hesitancy, and to gauge the effectiveness of vaccination counseling, as measured by activity on an authoritative pro-vaccine website.

The VaccinarSì website was created by members of the Italian Society of Hygiene, Preventive Medicine and Public Health to inform and educate the general population and the healthcare community about vaccinations and to oppose the anti-vaccination movement's spread on the internet. The website is organised into 5 main sections (vaccine-preventable diseases (VPDs), registered vaccines, benefits and risks of vaccinations, the prevention of vaccine misinformation, and travel immunisation). Its contents are validated by a scientific committee that includes more than 20 Italian and international experts on immunisation from academia and Italian National Health Services. Social network accounts (e.g., on Facebook, Instagram, and Twitter), launched between 2013 and 2014, are also associated with VaccinarSì's main web portal.

For the study, an anonymous validated questionnaire was administered in April 2017 at the main shopping centre of Palermo to 299 participants. They were then provided with approximately 15 minutes of tailored, face-to-face vaccination counseling by healthcare professionals and members of the study group. The purpose of this counseling was to address any doubts regarding the Sicilian vaccination schedule, VPDs and related vaccines, and possible or suspected adverse reactions to vaccinations. In addition, the participants received informative flyers, shopping bags, balloons, and a copy of the Sicilian immunisation schedule referring to VaccinarSì's website.

Selected findings among the 299 subjects enrolled:

• 12.7% were hesitant about vaccinations, and 4.7% said they were against vaccinations.
• General practitioners (GPs) and paediatricians were the main source of information in 81.3% of cases, followed by vaccination centre workers (16.1%). Official websites (15.1%), the mass media, and nongovernmental websites (24%) represented other sources of information about vaccinations.
• A higher probability of vaccination hesitancy/refusal was reported among subjects who considered the mass media, the internet, and friends or relatives the most reliable source of information (crude odds ratio (OR) = 2.09, confidence interval (CI) 95% 1.01-4.41, p-value = 0.05), among subjects who had no confidence in healthcare workers (HCWs) regarding vaccination topics (crude OR = 2.18, 95% CI 1.02-4.75, p-value = 0.05), and among subjects who considered hygiene, physical activity, or homeopathy, instead of vaccinations, the best strategies for the prevention of infectious diseases (crude OR = 7.39, 95% CI 3.32-16.44, p-value < 0.001), a number that was also significant in the multivariate analysis (adjusted OR = 7.01, 95% CI 2.88-17.09, p-value < 0.001).

Internet traffic from Palermo and Sicily (all the Sicilian cities in which survey participants lived were included in the analysis) to the VaccinarSì website was evaluated. Specifically, the number of unique visits to vaccinarsi.org, the number of new visitors, the number of pages viewed in each visit, and the duration of each visit were all compared between the 2 months before the first counseling activity (from February 8 to April 7 2017) and the 2 months afterward (from April 8 to June 7 2017). Moreover, average number of new unique visits to vaccinarsi.org in the 2 months after the intervention was compared with the same period of the 2 previous (2015, 2016) and subsequent (2018, 2019) years.

A considerable increase of all the vaccinarsi.org website indicators analysed was observed from the area in which survey participants lived. In particular, in the period April-June 2017 (after intervention counseling), a consistent and significant increase of the number of unique visits to vaccinarsi.org (n = 3,257) in comparison with 2 years before and after was reported from the Sicilian cities in which survey participants lived.

The researchers acknowledge that many other factors could have contributed to the increase of the VaccinarSì's website parameters analysed in the study before and after the intervention they conducted, such as the mass media/political level debate about the implementation of the Law 119/2017 that introduced 10 mandatory vaccinations for attending kindergarten. However, they contend that the georeferenced increase in both unique visits and new visitors to vaccinarsi.org during the 2 months after the intervention could suggest a positive impact of the vaccination counseling provided after the administration of the questionnaire.

In terms of strategic recommendations to emerge from the study, the researchers note that, as has been previously reported, HCWs can play an important role in vaccination counseling. "Only with tailored training in communicative vaccination strategies can the personal attitudes and counseling strategies of HCWs on vaccination topics be improved, making them public health opinion leaders who will provide the general population accurate information and lead to a community health advocacy about vaccination issues."