Vaccine refusal and hesitancy in Spain: an online cross-sectional questionnaire 

Vaccine refusal and hesitancy in Spain: an online cross-sectional questionnaire | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Vaccine refusal and hesitancy in Spain: an online cross-sectional questionnaire Agnes Huguet-Feixa, Eva Artigues-Barberà, Joaquim Sol, Xavier Gomez-Arbones, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4574634/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Apr, 2025 Read the published version in BMC Primary Care → Version 1 posted 4 You are reading this latest preprint version Abstract Blackground Vaccine refusal and hesitancy pose a critical challenge to public health, leading to delays in vaccination and compromising herd immunity. Method To address this issue, we conducted a comprehensive observational study on the adult Spanish population in 2021. Through an online questionnaire, we explored the sociodemographic and sociocultural factors, beliefs, and opinions of those refusing or holding hesitancy about vaccines, and their vaccination behaviours by vaccine type and sex. Results There were 1,312 respondents: 74.5% were female, 73.7% were between 31 and 59 years old, and 71.0% had university studies. Our findings revealed that vaccine refusal rates were relatively low (16.8%), and mainly associated with influenza vaccination (10.3%). Greater refusal of vaccination was observed in over 60 years old, in those expressing hesitancy due to vaccine components and opposing free and compulsory vaccination, unaware that vaccination protects the community and being against consuming cow’s milk and the use of infant formulas for breastfeeding. Vaccine hesitancy was greatest in individuals under 31 years old, women, parents of children under 15 years old, against compulsory vaccination, unaware that vaccination protects the community, with hesitancy due to vaccine costs, and in favour of alternative and complementary treatments. Conclusions These insights underscore the need for strategies to improve education about vaccination and dispel misconceptions are crucial for effectively reducing vaccine refusal and hesitancy across the population. anti-vaccination movement anti-vaccine vaccination refusal vaccine hesitancy Blackground Vaccination is a cost-effective public health measure that can prevent the spread of diseases and reduce the morbidity burden [ 1 ]. High vaccine uptake leads to a decline in the prevalence of vaccine-preventable diseases (VPDs) [ 2 ]. Vaccines are safe and effective and, although like medication they can cause adverse effects, these adverse effects are outweighed by individual and collective benefits [ 1 , 3 ]. The Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy concluded that vaccination hesitancy refers to delay or refusal of vaccination despite the availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence [ 4 ]. Declines in vaccination present threats to herd immunity [ 5 ]. According to the World Health Organization (WHO), 1.5 million child deaths from VPDs occur every year worldwide This is partly due to problems of access to vaccines for socio-economic reasons, and partly to vaccination hesitancy generated by the rise of anti-vaccine movements [ 6 , 7 ]. Vaccination hesitancy is considered a priority line of action for the WHO and a challenge for those countries working to close the immunisation gap [ 8 , 9 ]. The SAGE Group noted that the Vaccine Hesitancy Determinants Matrix displays the factors influencing the behavioural decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine/vaccination-specific influences [ 4 ]. A publication analysing the psychological factors that might motivate people in 25 countries to refuse vaccination showed that the best predictors of refusal were the following: high levels of conspiracy beliefs, low tolerance of perceived infringement of personal freedom, aversion to needles or blood, and religious beliefs [ 10 ]. Another review highlighted the complexity of factors related to acceptance or refusal of vaccines including demographic factors (ethnicity, age, sex, pregnancy, education, and employment), accessibility and cost of vaccines, personal responsibility and risk perceptions, trust in healthcare authorities and vaccines, safety and efficacy of new vaccines, and lack of information or misinformation [ 11 ]. In Spain, vaccination coverage is high but varies depending on the vaccine. Vaccination is offered by the national public health system, and most vaccines are provided free of charge and administered primarily in primary care settings, with minor differences between autonomous communities. Data published by the Spanish Ministry of Health in 2022 showed a slight increase from the previous year in primary vaccination coverage (Polio, DTaP, Hib, Hepatitis B, Meningococcus C, Pneumococcus), as evidenced by the percentage of the population receiving the second dose of the hexavalent vaccine (DTaP, Hib, Hepatitis B) increasing from 96.8% in 2021 to 97.6% in 2022. However, coverage of two doses of the Measles, Mumps, and Rubella (MMR) vaccine in 2022 was 92.6% which did not meet the target coverage of ≥ 95% needed to keep measles’ elimination status, even if coverage was achieved considering only one dose. After the positive effect of the COVID-19 pandemic on influenza vaccine coverage, there was a decreasing trend in influenza vaccine coverage in all population groups, while remaining higher than pre-pandemic levels [ 12 ]. Vaccine hesitancy had been previously studied in Spain in specific groups such as HCPs and epidemiologists, so we consider it interesting to study it in the general population. [ 13 , 14 ]. Our study aimed to characterise the profile of the Spanish population with vaccination refusal specifically and hesitancy in general, to help HCPs conduct targeted vaccination campaigns to improve vaccination coverage. With this objective, we used an online questionnaire to describe the socio-demographic and sociocultural characteristics, beliefs and opinions of those refusing to have vaccine and those with hesitancy about vaccination, and their vaccination behaviours by vaccine type and sex. Method Study Design We conducted an observational, cross-sectional study on individuals accessing an online survey from March to December 2021. The inclusion criteria required participants to be aged 18 years or older and to have the authority to make vaccination decisions for themselves or others in Spain. We obtained the information through an online, self-administered questionnaire designed by the project research team. A pilot test was performed before the definitive questionnaire was obtained. To ensure the rigor and validity of the study, an experienced research team with expertise in conducting surveys was involved, thereby guaranteeing the quality and reliability of the instrument. Both were registered on a Research Electronic Data Capture (REDCap) web platform stored on a centralized server where the data remain securely in the custody of the Institut Català de la Salut [Catalan Institute of Health]. Anonymous information was exported to the statistical packages used for later analysis. The REDCap platform generated a link [ 15 ] for participation in the survey that was disseminated through scientific societies, social networks, research institutes, paediatricians, and nurses in primary care. Variables The main variables of the questionnaire were: sociodemographic factors (sex, age, having children under 15 years old, level of education); sociocultural factors ( religious beliefs, culture, family); vaccine information variables (whether they have refused any vaccines and, in that case, the type of vaccine refused; who the refused vaccine was for; hesitancy due to vaccine components, associated diseases or to the payment of vaccines; whether they know that personal vaccination protects other people whether they would be in favour of free and compulsory vaccination; opinion about vaccines), variables of trust in the health system (sources of information about vaccines, whether HCPs can understand anti-vaccine arguments, whether HCPs have enough information to satisfy anti-vaccine people, whether when in doubt about vaccines they will consult the HCP); habits (type of diet, consumption of cow's milk, opinion on breastfeeding or artificial breastfeeding, opinion on alternative treatments or complementary treatments). Statistical Analysis The data were gathered in an anonymized database using the REDCap platform. We conducted a descriptive analysis of the findings, categorizing qualitative or ordinal data using absolute and relative frequencies. In the statistical analysis, only complete cases were considered, and missing values were assumed to be missing at random. We evaluated the relative frequency of the categorical variables using the Chi square test or Fisher's exact test and identified the variables that were both statistically significant and clinically relevant. In selected subgroups of interest, we identified the factors independently associated with these results. The relationship between the variables is quantified using Odds Ratios (ORs), with 95% confidence interval (CI) estimates, as a measure of association for risk. We used logistic regression to identify which factors are independently linked to vaccination refusal or to hesitancy due to vaccine components or diseases that have been associated to being vaccinated. We employed a stepwise conditional variable recall model that retains variables at an adjusted p-value of 0.10. This included factors that were statistically significant in our initial comparisons of two variables at a time. We report the likelihood of these factors as ORs and their statistical significance (as adjusted p-values), using a cut-off of p < 0.05 to define statistical significance. All analysis was conducted using SPSS software version 26.0. Ethical Considerations This study was approved by the ethics and clinical Research Committee of the Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), with code 20/221-P. The study was conducted following the principles of the Declaration of Helsinki. The variables collected were treated anonymously to guarantee the confidentiality of the data, as established in Regulation (EU) 2016/679 of the European Parliament and the Council of April 27 on Data Protection (RGPD) and the Spanish Organic Law 3/2018, of the 5th December 2018, regarding the protection of personal data and guarantees of digital rights. The database is kept by the principal investigator and the research team in an Excel format, protected by password access. An anonymized database was used for the analysis. Before conducting the survey, online informed consent was completed, accepted, and signed. Results Description of the study population and percentages of vaccine refusal and hesitancy (Table 1 ) Table 1 Description of the study population Sociodemographic data Total N = 1312 *Responders to Q25 n = 1294 Refusers n = 218 Sex: Men 326 (25.5%) 325 (25.5%) 53 (24.5%) Women 954 (74.5%) 952 (74.5%) 163 (75.5%) Age (recodified): 30 years old or less 180 (14.0%) 180 (14.0%) 25 (11.6%) 31–59 years old 948 (73.7%) 947 (73.8%) 151 (69.9%) 60 years old or more 159 (12.4%) 157 (12.2%) 40 (18.5%) University studies: No 374 (29.0%) 372 (28.9%) 58 (26.7%) Yes 915 (71.0%) 914 (71.1%) 159 (73.3%) Do you have sons or daughters under 15 years old? Yes 604 (46.9%) 603 (46.9%) 106 (48.6%) No 685 (53.1%) 683 (53.1%) 112 (51.4%) Your religious beliefs are: In favour of vaccination 467 (35.6%) 466 (36.0%) 51 (23.4%) Against vaccination 6 (0.5%) 6 (0.5%) 2 (0.9%) I have no opinion 237 (18.1%) 220 (17.0%) 61 (28.0%) I am not a believer 494 (37.7%) 494 (38.2%) 92 (42.2%) I do not know 108 (8.2%) 108 (8.3%) 12 (5.5%) Your culture is: In favour of vaccination 1111 (84.7%) 1109 (85.7%) 161 (73.9%) Against vaccination 14 (1.07%) 14 (1.08%) 9 (4.13%) I have no opinion 128 (9.76%) 112 (8.66%) 36 (16.5%) I do not know 59 (4.50%) 59 (4.56%) 12 (5.50%) Your family is: In favour of vaccination 1165 (88.8%) 1163 (89.9%) 164 (75.2%) Against vaccination 32 (2.44%) 32 (2.47%) 14 (6.42%) Has no opinion 90 (6.86%) 74 (5.72%) 31 (14.2%) I do not know 25 (1.91%) 25 (1.93%) 9 (4.13%) Opinion about vaccinations Total N = 1312 *Responders to Q25 n = 1294 Refusers n = 218 Have you ever refused a vaccine? 218 (16.8%) 1294 218 (16.8%) 1294 218 (100%) 218 Which vaccine have you refused? (choice = Diptheria) 15 (1.14%) 1312 15 (1.16%) 1294 15 (6.88%) 218 Which vaccine have you refused? (choice = Influenza) 135 (10.3%) 1312 135 (10.4%) 1294 135 (61.9%) 218 Which vaccine have you refused? (choice = Haemophilus influenzae type B) 8 (0.61%) 1312 8 (0.62%) 1294 8 (3.67%) 218 Which vaccine have you refused? (choice = Hepatitis A) 18 (1.37%) 1312 18 (1.39%) 1294 18 (8.26%) 218 Which vaccine have you refused? (choice = Hepatitis B) 28 (2.13%) 1312 28 (2.16%) 1294 28 (12.8%) 218 Which vaccine have you refused? (choice = Meningococcus ACWY(Nimenrix®, Menveo®)) 15 (1.14%) 1312 15 (1.16%) 1294 15 (6.88%) 218 Which vaccine have you refused? (choice = Meningococcus B (Bexero®, Trumemba®)) 18 (1.37%) 1312 18 (1.39%) 1294 18 (8.26%) 218 Which vaccine have you refused? (choice = Meningococcus C) 12 (0.91%) 1312 12 (0.93%) 1294 12 (5.50%) 218 Which vaccine have you refused? (choice = Pneumococcus) 15 (1.14%) 1312 15 (1.16%) 1294 15 (6.88%) 218 Which vaccine have you refused? (choice = Polio) 15 (1.14%) 1312 15 (1.16%) 1294 15 (6.88%) 218 Which vaccine have you refused? (choice = Rotavirus (Rotarix ®, Rotateq®)) 24 (1.83%) 1312 24 (1.85%) 1294 24 (11.0%) 218 Which vaccine have you refused? (choice = Tetanus) 40 (3.05%) 1312 40 (3.09%) 1294 40 (18.3%) 218 Which vaccine have you refused? (choice = Whooping cough) 14 (1.07%) 1312 14 (1.08%) 1294 14 (6.42%) 218 Which vaccine have you refused? (choice = Triple vírica (MMR)) 22 (1.68%) 1312 22 (1.70%) 1294 22 (10.1%) 218 Which vaccine have you refused? (choice = Papiloma virus HPV) 35 (2.67%) 1312 35 (2.70%) 1294 35 (16.1%) 218 Which vaccine have you refused? (choice = Varicella) 31 (2.36%) 1312 31 (2.40%) 1294 31 (14.2%) 218 Which vaccine have you refused? (choice = I do not remember) 37 (2.82%) 1312 37 (2.86%) 1294 37 (17.0%) 218 Number of vaccines refused 0.37 (1.54) 1312 0.37 (1.55) 1294 2.21 (3.19) 218 Who was the vaccine for? (choice = My sons and/or daughters) 75 (5.72%) 1312 75 (5.80%) 1294 75 (34.4%) 218 Who was the vaccine for? (choice = My mum or dad) 8 (0.61%) 1312 8 (0.62%) 1294 8 (3.67%) 218 Who was the vaccine for? (choice = Me) 160 (12.2%) 1312 160 (12.4%) 1294 160 (73.4%) 218 Who was the vaccine for? (choice = Others (open)) 8 (0.61%) 1312 8 (0.62%) 1294 8 (3.67%) 218 Has the fact that vaccines contain components like thiomersal, aluminium, mercury or formaldehyde caused you any doubts about vaccines? 362 (28.1%) 1287 359 (28.0%) 1284 99 (45.4%) 218 Has the fact that vaccines have been linked to diseases such as cancer, allergies, autism, sudden infant death syndrome, multiple sclerosis, asthma, and alterations of the immune system caused you any doubts about vaccines? 399 (30.9%) 1290 398 (30.9%) 1288 101 (46.3%) 218 Has the fact that you have to pay for any of the vaccines caused you any doubts about vaccination? 374 (29.0%) 1288 373 (29.0%) 1286 68 (31.8%) 214 Do you agree with vaccines: 1291 1288 214 Totally agree 982 (76.1%) 982 (76.2%) 112 (52.3%) Slightly agree 216 (16.7%) 215 (16.7%) 60 (28.0%) Indifferent 32 (2.48%) 32 (2.48%) 13 (6.07%) Slightly disagree 44 (3.41%) 43 (3.34%) 18 (8.41%) Totally disagree 17 (1.32%) 16 (1.24%) 11 (5.14%) ¹Responded to the question of whether they had ever refused a vaccine Sum of percentages might be slightly different from 100 because of roundings. There was a total of 1312 respondents to the survey: 74.5% were females and 25.5% males; 14.0% were under 31 years old, 73.7% between 31–59, and 12.4% over 59. Out of all the respondents, 1294 responded to the question of whether they had ever refused a vaccine, with 16.8% (218/1294) of these claiming to have indeed refused vaccines. Of the 218 respondents who had refused vaccines, the most commonly refused vaccine was for influenza (61.9%) followed by tetanus (18.3%) and papilloma (HPV) (16.1%). Other vaccines refused included the following: chicken pox (14.2%); hepatitis B (12.8%); MMR (10.1%); hepatitis A (8.3%); and diphtheria, pneumococcus, and polio (each 6.9%). A small proportion declined the vaccine for pertussis (6.4%), meningococcus C (5.5%), and haemophilus influenzae type B (3.7%). A percentage of 17.0% of respondents who had refused vaccines could not remember which vaccine they refused and 5.5% did not specify. Among the vaccines not funded by Spanish Health System in 2019, refusal rates were 11.0% for rotavirus, 8.3% for Meningococcus B, and 6.9% for Meningococcus ACWY. Of those who had refused vaccines, the majority (66%) had refused just one vaccine, while 34% had refused two or more. Most (73.4%) had refused vaccines for themselves, while some (34.4%) for their children, and just a few (3.7%) for their parents or others. Hesitancy due to vaccine components was cited by 28.1% of respondents, associations with disease that have been linked to vaccines by 30.9%, and the fact that some vaccines must be paid for by 29.0%. When looking at the overall support respondents showed for vaccines, a significant majority (76.1%) expressed strong support for vaccines, 16.7% showed slight agreement, and only a small fraction expressed indifference, or a slight or strong disagreement to vaccines (2.4%, 3.4%, and 1.3% respectively). Socio-demographic and sociocultural characteristics, beliefs, and opinions of the population who refused vaccines We observed a significant positive association between vaccination refusal, being 60 years old or older, and with anti-vaccination culture and family (Table A1). There was also an association between refusing vaccination and hesitancy due to the vaccine components or associated diseases, a lack of understanding of the community-wide protection benefits of individual vaccination, and a reluctance to support compulsory vaccination even if it was free. Respondents who had refused vaccination were less inclined to view HCPs and healthcare websites as reliable sources of vaccine information than those who had not refused vaccination, and they trusted more friends. Moreover, respondents who had refused vaccination felt that HCPs lacked the information to address anti-vaccine hesitancy and would not consult HCPs, if they had a vaccine question. Finally, vaccination refusal, apart from being strongly related to total disagreement with vaccines, was also strongly related to opposition to the use of infant formula, or consumption of cow's milk, and support of alternative medicine. (Table A2). In our multivariate logistic regression analysis, we found a statistically significant independent association between refusal of vaccination with the following variables: being 60 years and older; having hesitancy due to vaccine components; being against mandatory and free vaccination; not knowing that vaccination protects the community; and being against consuming cow’s milk and the use of infant formulas for breastfeeding (Table 2 ). Table 2 Dependent variable: Refusal of vaccination Significant independent variable p-value OR 95% CI OR inf 95% CI OR sup Age group 30 years old or less 0.004 0.403 0.219 0.742 31–59 years old 0,001 0.491 60 years old or more Ref Ref Knowledge of protecting more people 0.005 0.390 0.202 0.754 Desire for free and compulsory vaccination 0.000 0.278 0.200 0.386 Hesitancy due to vaccine components 0.003 1.676 1.195 2.352 Opinion on use of infant formula 0.069 0.684 0.454 1.030 Opinion on consumption of cow’s milk 0.021 0.607 0.397 0.929 Constant 0.005 3.521 Socio-demographic and sociocultural characteristics, beliefs and opinions of the population with hesitancy due to vaccine components, associated diseases, or payment Women, parents with children under 15 years old and individuals with a culture or family against vaccination were more likely to express hesitancy due to vaccine components. Also, a heightened frequency of hesitancy due to the diseases associated with vaccines was seen among certain groups. In particular, individuals under 30 years old, women, those without a university education, those with children under 15 years old, and those aligned with a culture or family against vaccination (Table A1). Individuals expressing hesitancy due to vaccine components (Table A3) or associated diseases (Table A4) were more hesitant about the payment for vaccines, were more likely unaware that individual vaccination protects the community and less likely to be in favour of free and compulsory vaccination. As for their information sources, they were more likely to report that social networks, family, and friends were reliable sources of information about vaccines. Conversely, they expressed more distrust in HCPs, and believed that HCPs are not a reliable source of information to satisfy anti-vaccine sentiments and would not consult an HCP if they had a question. There was greater hesitancy due to vaccine components or associated diseases among respondents who disagreed with vaccines, infant formula milks, cow's milk consumption or who had diets other than the Mediterranean diet and favoured alternative and complementary treatments (Table A3 and A4). In our multivariate logistic regression analysis, we found a statistically significant independent association between hesitancy due to vaccine components or associated diseases with individuals under 30 years old, women, those with children under 15 years old, individuals against free and compulsory vaccination, those unaware of the community protection aspect of vaccination, individuals with hesitancy about vaccine payment or with anti-vaccine attitudes, and in favour of alternative and complementary treatments (Table 3 ). Table 3 Dependent variable: Hesitancy due to vaccine components or associated diseases Significant independent variables p-value OR 95%CI OR Inf 95% CI OR Sup Age group 30 years old or less 0.190 1,384 0.851 2.253 31–59 years old 0.093 0.695 0.454 1.062 60 years old or more Ref Ref Gender (binary) 0.009 1.494 1.104 2.023 Children under 15 years old 0.006 0.669 0.502 0.891 Knowledge of protecting more people 0.019 0.418 0.202 0.864 Desire for free and compulsory vaccination 0.000 0.436 0.331 0.573 Hesitancy due to payment for a vaccine 0.000 0.459 0.351 0.600 Opinion on vaccination 0.002 0.307 0.148 0.637 Use of alternative treatments 0.000 0.488 0.350 0.680 Use of complementary treatments 0.001 1.549 1.183 2.029 Constant 0.000 41.261 There was more hesitancy due to the payment of vaccines among people younger than 30 years old, people without a university degree, and parents with children younger than 15 years old (Table A1). Those who were not in favour of free and compulsory vaccination, who were more likely to consider friends as reliable sources of information on vaccines, were also more likely to have hesitancy due to the payment of vaccines. People with hesitancy about vaccine payment reported that HCPs did not have enough information to satisfy people with anti-vaccine concerns. They also reported that they disagreed more with vaccines, the use of infant formula, and the consumption of cow's milk, and more of them were in favour of alternative treatments (Table A5) Vaccination behaviours by vaccine type and sex The socio-demographic features associated with various vaccines types mirrored the overall profile of vaccine refusal, albeit with some nuanced distinctions. Notably, individuals aged 60 years or older exhibited a higher refusal of influenza and tetanus vaccines. Men displayed a greater tendency to refuse tetanus vaccines, while university students showed a higher refusal to rotavirus vaccines but a lower refusal to tetanus vaccines. Parents with children under 15 years old display a higher refusal of vaccines for Haemophilus influenzae type B, Meningococcal B, and Rotavirus (Table A6). Men showed a higher refusal rate for tetanus vaccination, whereas women demonstrated a greater inclination to refuse vaccines for their children (Table A7). Additionally, women, particularly those without children under 15 years old showed more hesitancy due to vaccine components or associated diseases (Table A8). Regarding vaccine information sources, there were no discernible sex differences in the perceived reliability of HCPs, family or friends. However, women tended to view health websites as more reliable, while men leaned towards social networks, television and radio. Moreover, a larger proportion of men strongly disagreed with vaccines, in comparison with women. Finally, women showed a stronger preference for complementary treatments, although no sex differences were seen regarding alternative treatments (Table A7). Discussion In our study, we found that respondents generally favored vaccination, with a refusal prevalence of 16.8%. This rate aligns with published data on the intention to refuse the COVID-19 vaccine in the Catalan population during the same year as the study. This indicates that the vaccine hesitancy observed in our sample is consistent with broader regional trends. Additionally, within this inquiry, we detected an increase in doubts about vaccines as a result of the pandemic [ 16 ], which mirrors global trends of heightened vaccine skepticism fueled by misinformation and rapidly evolving scientific guidelines during the COVID-19 crisis. Although official data regarding vaccine rejection are not at our disposal, we do have authoritative records delineating vaccine acceptance trends. These records evince that vaccination coverage rates in Spain for the years 2021 and 2023 remained comparably stable. Notably, in 2024, a marginal augmentation in vaccination coverage for MMR and hexavalent vaccines was observed. This suggests a positive trend in the uptake of these essential vaccines, possibly due to public health campaigns and increasing public awareness of the benefits of vaccination. However, this positive trend was contrasted by a diminished coverage for influenza compared to the year 2021 [ 12 ]. Therefore, we believe the data on hesitancy and refusal of vaccination could be valuable in the current scenario of vaccination in Spain in 2024, as it highlights areas needing targeted interventions to improve vaccine uptake and address ongoing public concerns about vaccine safety and efficacy The SAGE Vaccine Hesitancy Working Group categorize vaccine hesitancy using a matrix of contextual influences, individual/social influences, and vaccine and vaccination specific issues [ 4 , 17 ]. Our study delved into several contextual influences, particularly focusing on the sociodemographic and sociocultural characteristics of the population. Analysis of respondent age revealed higher rates of vaccine refusal among those over 60 years old. This does not coincide with previous findings from other studies, where a greater likelihood of vaccination was detected in older people because of increased health concerns and susceptibility to illness [ 11 , 18 – 21 ]. We believe that the reason for this finding may stem from the significant rejection in our older population of the influenza vaccination, which is primarily targeted at people over 65 years old or with underlying pathologies in Spain, and from the difficulties already described in previous publications to achieve satisfactory vaccination coverage against influenza [ 21 – 24 ]. We also detected greater hesitancy among people under 30 years old, particularly due to concerns about diseases associated with vaccines and the cost of vaccines. This finding is consistent with previously published studies [ 11 , 18 – 21 , 25 ] and underscores the need for vaccination campaigns tailored to specific age groups, addressing their unique concerns and barriers. When considering sex, our study revealed that women and parents with children under 15 years old, showed greater hesitancy due to the components of vaccines or diseases that have been associated with vaccines. Greater doubts were detected in women without children under 15 years old than in men. Moreover, women were more likely to refuse vaccines for their children, aligning with previous studies, which show a greater predisposition to vaccination in men than in women, and less acceptance and greater hesitancy in parents [ 11 , 18 , 26 , 27 ]. Concretely, women with young children are more concerned about vaccinating their children, necessitating targeted strategies to bolster the trust and confidence, as previously proposed [ 11 , 18 , 27 , 28 ]. Regarding education level, individuals without a university education exhibited greater hesitancy due to associated diseases or vaccine payment. This aligns with published studies that show that the higher the level of education, the greater the acceptance of vaccines [ 11 , 18 , 20 , 23 , 29 ]. Cultural, religious, and family beliefs emerged as influential factors associated with hesitancy and decision about vaccination, with a greater predisposition to get vaccinated if the sociocultural environment is provaccine. These results echo findings from prior studies [ 3 , 10 , 18 ]. In terms of political and policy-related contextual influences, most respondents favoured free and compulsory vaccination, except those who refused vaccines or expressed hesitation because of components, associated diseases, or payment for vaccines. Although in recent years there has been growing traction for anti-vaccine movements, most of the population seems to be in favour of compulsory vaccination policies, as evidenced in a 2019 review. Moreover, it seems that support towards mandatory policies increases after their implementation [ 30 ]. Nonetheless, efforts to improve vaccine acceptance, such as enhancing education and providing proof of the efficacy, benefits and safety of vaccines, remain crucial [ 31 ]. We observed greater vaccine refusal and hesitancy among individuals who deemed health professionals or websites unreliable sources of vaccine information, while considering friends, family, or social networks as reliable sources. These results reinforce previous publications which stated that the crisis in the vaccination system and the resurgence of anti-vaccine movements are due to the increased accessibility of information and the reduced credibility of HCPs [ 5 , 32 ]. Exposure to anti-vaccine content on social media was associated with refusal and hesitancy to vaccinate [ 33 – 37 ], highlighting the critical need to combat misinformation to mitigate its effects [ 35 , 36 ]. Our study also suggests that a lack of trust in HCPs is associated with greater vaccine refusal and hesitancy. This aligns with existing reviews and published studies that conclude that vaccine safety and trust in health authorities are the main factors in promoting vaccine acceptance [ 11 , 38 ]. According to the WHO's "3Cs" model (confidence, compliance, convenience), confidence in vaccines and in the healthcare system constitute one of the three main determinants of vaccine hesitancy [ 4 , 7 , 17 ]. We detected a greater refusal of the vaccines for influenza, tetanus, papilloma, and varicella (chicken pox). Mostly individuals refused vaccines for themselves and, to a lesser extent, their children. These findings mirror other international studies which highlight the difficulties in achieving satisfactory vaccination coverage for influenza and papillomavirus [ 31 , 36 , 39 ]. Data published by the Spanish Ministry of Health also corroborate these difficulties in vaccination coverage for influenza, papilloma, and varicella in 2021–2022. In Spain, the recommendation to maintain vaccination coverage ≥ 95% for MMR vaccination in 2021–2022 was not achieved [ 12 ] and the goal of maintaining measles and rubella elimination status was not met [ 40 ]. Again, although there are high coverage rates for tetanus in primary vaccination with the hexavalent vaccine, vaccination coverage with Td decreases in adolescents [ 12 ]. In our study, we found a greater refusal of tetanus vaccine than the diphtheria vaccine, although tetanus and diphtheria vaccines are usually administered together. We attribute this difference and other similar ones to a possible lack of knowledge of the vaccination schedule in our reference population or to a greater popular knowledge of tetanus vaccine because of its indication for administration in certain wounds. Our study revealed a relationship between having hesitancy due to vaccine components and refusing a vaccine. It also showed that having hesitancy due to vaccine components or associated diseases were associated with hesitancy due to vaccine payment. Earlier research has found that accessibility and cost, along with safety and efficacy were reasons for hesitancy [ 11 , 17 , 41 ]. In most Spanish autonomous communities, the Meningococcal ACWY and Meningococcal B vaccines are now part of the public vaccination schedule and thus should no longer be a reason for hesitancy because of costs in these cases [ 42 ]. Collective responsibility was assessed and greater refusal and hesitancy was detected in respondents who were unaware that individual vaccination protects the community. The concept of collective responsibility was one of five factors that affect people’s perception of vaccines, along with confidence (trust in vaccine efficacy and safety), complacency (perception about the risk of the disease), calculation (weighing the risks and benefits of vaccines) and constraint (accessibility of information about the vaccine). These are part of the 5Cs model [ 38 ], which extends from the 3C model introduced by the WHO SAGE Working group [ 4 ]. We intended to study the profile of the local population with vaccine hesitancy and we observed heightened hesitancy among people who disagreed with cow's milk consumption or the use of infant milk formulas, and those who adhered to a non-Mediterranean diet or favoured alternative or complementary treatments for healthcare. This profile of a population with a preference for natural therapies, skepticism towards established scientific positions, and greater reticence towards healthcare systems and HCPs, seems to be the profile of vaccine hesitancy detected in primary care. In another study published in the UK in the same year, rejection and hesitancy towards vaccination were also associated with low confidence in the health service [ 25 ]. To address vaccine hesitancy, we urge institutions and governmental bodies to seek strategies to enhance trust in HCPs, public health systems, authorities, and health policies. Encouraging shared participation in the formulation of vaccine recommendations is paramount [ 38 ]. Additionally, as previously suggested by some authors, novel approaches such as analysing population opinions on vaccination through social networks using artificial intelligence to complement traditional survey methods, can provide a more comprehensive understanding of vaccine refusal and hesitancy dynamics and allow targeted interventions. Such initiatives can facilitate effective engagement with diverse communities and foster informed decision-making regarding vaccination [ 34 , 43 – 46 ]. One of the limitations of this study is the inherent recruitment bias associated with the online survey method, which restricted participation to individuals with internet access. This can produce selection bias problems because there are different probabilities of being involved in the study depending on where people live, their level of education, and their age. Therefore, this may hinder the generalization of the results. However, given that 96.1% of Spanish households have internet access and 85% of Spaniards are users of social networks [ 47 , 48 ], the reach of our survey remains substantial. Another possible limitation is potential respondent repetition, although, we anticipate minimal impact on the final results because of expected low rate of repetition. Additionally, our sample skewed towards women and people with a university education, this could limit the interpretation and generalization of our study to the broader population. Finally, reaching the anti-vaccine population posed challenges, as interactions with these groups is difficult. To mitigate eventual bias deriving from this, in our sample size calculation, we considered that the proportion of antivaccine responses would be much lower than the proportion of pro-vaccine responses. Despite these limitations, our study provides valuable insights into vaccine refusal and hesitancy, but caution is warranted in extrapolating findings to the entire population. Conclusions Vaccination refusal in our surveyed population was low and mainly related to refusal of influenza vaccination, although hesitancy arguments related to vaccine safety were detected, which could compromise vaccination coverage. Vaccine refusal was mainly associated with individuals over 60 years old, characterized by hesitancy towards vaccine components, a resistance to compulsory vaccination, and a lack of awareness regarding vaccination’s community-wide protection benefits. Furthermore, resistance extended to dietary choices, notably being against cow's milk and the use of infant formulas for breastfeeding. Vaccine hesitancy, on the other hand, was mainly associated with a younger demographic of people under 30 years old, typically women, parents of young children under 15 years old, and against compulsory vaccination. They were generally also unaware that vaccination protects the community, with hesitancy about vaccine payment or with anti-vaccine attitudes, and in favour of alternative and complementary treatments. In general, greater hesitancy to vaccination was detected in women and they reported a greater refusal to vaccinate their children than men. Addressing these complexities requires proactive health policies aimed at strengthening trust in scientific positions and HCPs. Additionally, strategies must be tailored to enhance community engagement and ensure sufficient education regarding vaccination, especially among populations with lingering doubts. Multifaceted approaches are indispensable for navigating the intricacies of vaccine acceptance and safeguarding public health in the face of evolving challenges and threats to established progress made at reducing vaccine refusal and hesitancy. Abbreviations VPDs Vaccine-preventable Diseases SAGE Strategic Advisory Group of Experts WHO World Health Organization DTaP Diphtheria, Tetanus, Pertussis MMR Measles, Mumps, and Rubella HCPs Healthcare professionals REDCap Research Electronic Data Capture Declarations Ethics approval and consent to participate This study was approved by the Ethics and Clinical Research Committee of the Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), with code 20/221-P. The study was conducted following the principles of the Declaration of Helsinki. Informed consent was obtained from all the subjects involved in the study. Consent for publication Not applicable Availability of data and materials The data are hosted on the research team's internal servers and will be provided under reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by Ajuts a Projectes en Projectes en Recerca en Atenció Primària-Diputació Lleida 2021-1a Edició (Ajut PICARD) modalitat projecte (4R22/152) y modalitat publicació i traducció d'articles (9F22/017) and by BECA AEPap-FPS 2020 for research in Primary Care Paediatrics. Authors’ contributions AH-F, EA-B, MO-B contributed to the study concept and research design, selected, and reviewed the literature on vaccination. JS and XG-A participated in the acquisition, analysis, and interpretation of data. AH-F, EA-B, MO-B, JS, XG-A and PG participated in the writing and critical review of the manuscript and approved the final version. AH-F and Group MC-MUVA contributed to the recruitment. Acknowledgments Data collection would not have been possible without the collaboration of the MC- MUVA work group, the Xarxa de Recerca en Pediatria d'Atenció Primària [Research Network of Primary Care Paediatrics], and the Societat Catalana de Pediatria [Catalan Society of Paediatrics]. Our special thanks go to the dedicated investigators and participants. MC-MUVA work group: Rebecca Oglesby, Merce Font Arbó, Lidia Sanz Borrell, Mireia Biosca Pàmies, Marta Pifarre Ortiz, Sara Martí Martí, Daniel Gros Esteban, Laura Guix Cliville, Noelia Diaz Charles, Silvia Prado Muñoz, Susana Perez Osuna, Mercè Giribet Folch, Magda Riera Veciana, Carles Gatius Tonda, Laura Seoane Barbosa, Pilar Serra Solans, Míriam Poblet, M. José Castañ Castillo, Elena Alcover Bloch, Anna Castan, Magda Barberà Farré, Sara Serra Font, Mònica Martinez, Imma Caubet Busquet, Maria Planella Cornudella, Gema Terrer Manrique, Raul Morales, Anna Gatell Carbo, Carme Farran Balcells,Carmen Gómez Seara, Viktoriya Atroshchenko Shushko, Margaret Creus Verni, Veronida Mª Karcz, Judith Palacin Aguilà, Joana Garcia Hinojosa, Mihaela Cozar, Rosa Aran Padullés, Ramón Capdevila Bert,Montse Crespo Pons, Maria Jose Lara Tostado, Isabel Segarra Solanes, Enmanuel Aneudi Estevez Genao, Raquel Plasencia Atienza, Maria Chiné Segura, Meritxell Pelegrí Romeo, Montse Farran Jové, Carme Trilla Felis, Rubén Lopez Ruiz, Iratxe Olabegoya Estrela, Roser Racero Maire, Sonia Asensio, Merce Lozano Vergara, Mercè Cortés Lladó, Àngels Font Anglada, Sara Borrat Padrosa, Maria Payan Sala, Bárbara Montilla Cabrera, Samanta Barisonzi Zambrano, Almudena Sanchez, Cristina Casademont, Pyrene Martinez, Anna M. Ristol Perxés, Irene Gómez i Pérez, Jaume Miquel Salsas. References OMS. Vacunas e inmunización: la seguridad de las vacunas. 2020 [accessed 2023-11-26]. https://www.who.int/es/news-room/questions-and-answers/item/vaccines-and-immunization-vaccine-safety . Chen C, Yang Q, Tian H, Wu J, Chen L, Ji Z, et al. Bibliometric and visual analysis of vaccination hesitancy research from 2013 to 2022. Hum Vaccin Immunother. 2023;19(2):2226584. Swingle CA. How Do We Approach Anti-Vaccination Attitudes? Mo Med. 2018;115(3):180–1. Meeting of the Strategic Advisory Group of Experts on immunization. October 2017 – conclusions and recommendations. Wkly Epidemiol Rec. 2017;92(48):729–47. Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018;10(7):e2919. Tafuri S, Gallone MS, Cappelli MG, Martinelli D, Prato R, Germinario C. Addressing the anti-vaccination movement and the role of HCWs. Vaccine. 2014;32(38):4860–5. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161–4. OMS. Diez cuestiones de salud que la OMS abordará este año. 2019 [Accessed 20 May 2020]. https://www.who.int/es/news-room/spotlight/ten-threats-to-global-health-in-2019 . Ozawa S, Yemeke TT, Evans DR, Pallas SE, Wallace AS, Lee BY. Defining hard-to-reach populations for vaccination. Vaccine. 2019;37(37):5525–34. Hornsey MJ, Harris EA, Fielding KS. The psychological roots of anti-vaccination attitudes: A 24-nation investigation. Health Psychol. 2018;37(4):307–15. Truong J, Bakshi S, Wasim A, Ahmad M, Majid U. What factors promote vaccine hesitancy or acceptance during pandemics? A systematic review and thematic analysis. Health Promot Int. 2022;37(1). Vacunas y Programa de Vacunación. Coberturas de Vacunación. Datos Estadísticos. Ministerio de Sanidad. Gobierno de España.2023 [accessed 2024-01-07]. https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/calendario-y-coberturas/coberturas/home.htm . Picchio CA, Carrasco MG, Sagué-Vilavella M, Rius C. Knowledge, attitudes and beliefs about vaccination in primary healthcare workers involved in the administration of systematic childhood vaccines, Barcelona, 2016/17. Euro Surveill. 2019;24(6). Caballero P, Astray J, Domínguez Á, Godoy P, Barrabeig I, Castilla J, et al. [Validation of the questionnaire on vaccines and hesitancy to be vaccinated in the Spanish Society of Epidemiology]. Gac Sanit. 2023;37:102329. IDIAP JordiGol. REDCap. [accessed 2023-02-06]. https://redcap.link/uj4jozhy . Huguet-Feixa A, Artigues-Barberà E, Sol J, Godoy P, Ortega Bravo M. Effects of the COVID-19 Pandemic on the Decision and Doubts About Vaccination in Catalonia: Online Cross-sectional Questionnaire. JMIR Form Res. 2023;7:e41799. Larson HJ, Jarrett C, Schulz WS, Chaudhuri M, Zhou Y, Dube E, et al. Measuring vaccine hesitancy: The development of a survey tool. Vaccine. 2015;33(34):4165–75. Joshi A, Kaur M, Kaur R, Grover A, Nash D, El-Mohandes A. Predictors of COVID-19 Vaccine Acceptance, Intention, and Hesitancy: A Scoping Review. Front Public Health. 2021;9:698111. Gagneux-Brunon A, Detoc M, Bruel S, Tardy B, Rozaire O, Frappe P, et al. Intention to get vaccinations against COVID-19 in French healthcare workers during the first pandemic wave: a cross-sectional survey. J Hosp Infect. 2021;108:168–73. Troiano G, Nardi A. Vaccine hesitancy in the era of COVID-19. Public Health. 2021;194:245–51. Rönnerstrand B. Social capital and immunisation against the 2009 A(H1N1) pandemic in Sweden. Scand J Public Health. 2013;41(8):853–9. Mesch GS, Schwirian KP. Social and political determinants of vaccine hesitancy: Lessons learned from the H1N1 pandemic of 2009–2010. Am J Infect Control. 2015;43(11):1161–5. Börjesson M, Enander A. Perceptions and sociodemographic factors influencing vaccination uptake and precautionary behaviours in response to the A/H1N1 influenza in Sweden. Scand J Public Health. 2014;42(2):215–22. Ferrante G, Baldissera S, Moghadam PF, Carrozzi G, Trinito MO, Salmaso S. Surveillance of perceptions, knowledge, attitudes and behaviors of the Italian adult population (18–69 years) during the 2009–2010 A/H1N1 influenza pandemic. Eur J Epidemiol. 2011;26(3):211–9. Soares P, Rocha JV, Moniz M, Gama A, Laires PA, Pedro AR et al. Factors Associated with COVID-19 Vaccine Hesitancy. Vaccines (Basel). 2021;9(3). Damnjanović K, Graeber J, Ilić S, Lam WY, Lep Ž, Morales S, et al. Parental Decision-Making on Childhood Vaccination. Front Psychol. 2018;9:735. Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust. Pediatrics. 2006;117(5):1532–41. Hilton S, Smith E. Public views of the UK media and government reaction to the 2009 swine flu pandemic. BMC Public Health. 2010;10:697. Myers LB, Goodwin R. Determinants of adults' intention to vaccinate against pandemic swine flu. BMC Public Health. 2011;11(1):15. Seale H, Leask J, Macintyre CR. Awareness, attitudes and behavior of hospital healthcare workers towards a mandatory vaccination directive: two years on. Vaccine. 2011;29(21):3734–7. Gualano MR, Olivero E, Voglino G, Corezzi M, Rossello P, Vicentini C, et al. Knowledge, attitudes and beliefs towards compulsory vaccination: a systematic review. Hum Vaccin Immunother. 2019;15(4):918–31. Larson HJ, Schulz WS. Reverse global vaccine dissent. Science. 2019;364(6436):105. Margolis MA, Brewer NT, Shah PD, Calo WA, Gilkey MB. Stories about HPV vaccine in social media, traditional media, and conversations. Prev Med. 2019;118:251–6. Argyris YA, Monu K, Tan PN, Aarts C, Jiang F, Wiseley KA. Using Machine Learning to Compare Provaccine and Antivaccine Discourse Among the Public on Social Media: Algorithm Development Study. JMIR Public Health Surveill. 2021;7(6):e23105. Badur S, Ota M, Öztürk S, Adegbola R, Dutta A. Vaccine confidence: the keys to restoring trust. Hum Vaccin Immunother. 2020;16(5):1007–17. Dunn AG, Surian D, Leask J, Dey A, Mandl KD, Coiera E. Mapping information exposure on social media to explain differences in HPV vaccine coverage in the United States. Vaccine. 2017;35(23):3033–40. Burki T. The online anti-vaccine movement in the age of COVID-19. Lancet Digit Health. 2020;2(10):e504–5. Paterson P, Meurice F, Stanberry LR, Glismann S, Rosenthal SL, Larson HJ. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34(52):6700–6. Ahmed N, Quinn SC, Hancock GR, Freimuth VS, Jamison A. Social media use and influenza vaccine uptake among White and African American adults. Vaccine. 2018;36(49):7556–61. Plan estratégico para la eliminación del sarampión y. la rubeola en España 2021–2025: Ministerio de Sanidad. Gobierno de España; 2021 [accessed 2024-01-19]. . Betsch C, Schmid P, Heinemeier D, Korn L, Holtmann C, Böhm R. Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination. PLoS ONE. 2018;13(12):e0208601. Vacunas y Programa de Vacunación. Calendarios de vacunación en las Comunidades Autónomas.: Ministerio de Sanidad. Gobierno de España.; 2023 [accessed 2023-01-07]. ttps://www.sanidad.gob.es/areas/promocionPrevencion/vacunaciones/calendario-y-coberturas/calendario/Calendario_CCAA.htm . Hussain A, Tahir A, Hussain Z, Sheikh Z, Gogate M, Dashtipour K, et al. Artificial Intelligence-Enabled Analysis of Public Attitudes on Facebook and Twitter Toward COVID-19 Vaccines in the United Kingdom and the United States: Observational Study. J Med Internet Res. 2021;23(4):e26627. Kwok SWH, Vadde SK, Wang G. Tweet Topics and Sentiments Relating to COVID-19 Vaccination Among Australian Twitter Users: Machine Learning Analysis. J Med Internet Res. 2021;23(5):e26953. To QG, To KG, Huynh VN, Nguyen NT, Ngo DT, Alley S, et al. Anti-vaccination attitude trends during the COVID-19 pandemic: A machine learning-based analysis of tweets. Digit Health. 2023;9:20552076231158033. Ahmed W, Vidal-Alaball J, Vilaseca JM. A Social Network Analysis of Twitter Data Related to Blood Clots and Vaccines. Int J Environ Res Public Health. 2022;19(8). Idescat. Llars amb accés a Internet: Institut d'Estadística de Catalunya; 2022 [Accessed 28 Nov 2023]. https://www.idescat.cat/indicadors/?id=ue&n=10144 . Statista. Penetración de las redes sociales en España de 2010 a 2023 2023 [Accessed 28 Nov 2023]. https://es.statista.com/estadisticas/910163/redes-sociales-porcentaje-de-usuarios-por-comunidad-autonoma-en-espana/ . Additional Declarations No competing interests reported. Supplementary Files AdditionalFile.docx Cite Share Download PDF Status: Published Journal Publication published 28 Apr, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 19 Jun, 2024 Editor assigned by journal 16 Jun, 2024 Submission checks completed at journal 16 Jun, 2024 First submitted to journal 13 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4574634","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316216802,"identity":"85b6e757-f851-4372-9b0d-a39ca385133e","order_by":0,"name":"Agnes Huguet-Feixa","email":"","orcid":"","institution":"CAP Rambla Ferran, Atenció Primària, Gerència Territorial de Lleida, Institut Català de la Salut, Rambla Ferran, 44, 25007 Lleida, Spain","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Agnes","middleName":"","lastName":"Huguet-Feixa","suffix":""},{"id":316216806,"identity":"caceb289-9a03-4a15-9095-1b0a04651769","order_by":1,"name":"Eva Artigues-Barberà","email":"","orcid":"","institution":"Atenció Primària, Gerència Territorial de Lleida, Institut Català de la Salut, Rambla Ferran, 44, 25007 Lleida, Spain","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Artigues-Barberà","suffix":""},{"id":316216809,"identity":"aef2ec76-7c14-465c-bd63-8bac75205690","order_by":2,"name":"Joaquim Sol","email":"","orcid":"","institution":"Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIA-PJGol), Gran Via de les Corts Catalanes, 587, 08007 Barcelona, Spain","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Joaquim","middleName":"","lastName":"Sol","suffix":""},{"id":316216810,"identity":"f668a078-0498-4bb5-91cb-1ac9f95a5c4f","order_by":3,"name":"Xavier Gomez-Arbones","email":"","orcid":"","institution":"University of Lleida","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xavier","middleName":"","lastName":"Gomez-Arbones","suffix":""},{"id":316216811,"identity":"b304d908-f147-425e-b8b0-7627378df346","order_by":4,"name":"Pere Godoy","email":"","orcid":"","institution":"Institut de Recerca Biomèdica de Lleida, Department of Experimental Medicine, University of Lleida, Lleida, Spain","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pere","middleName":"","lastName":"Godoy","suffix":""},{"id":316216812,"identity":"2811380c-c16d-4239-a5f1-507ae820bf71","order_by":5,"name":"Marta Ortega Bravo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABM0lEQVRIie2RMUvDQBTH33FwXS5mzSD6CYSUQFDQ5KtUAp10FxSsBC5L0s4B/RrFMeGgWe4DZFQC6tDhpCBRWvESRZEmugrmx/GHO96P9x4H0NHxl9noASQUQB2c/FaMRlUS/KmQQf1Oq2i2v5T3KqDmj8pOEN3fyBdHKThN5mewqU/E4uHx2tl2Ad8u5Lpii6x/EY89pZBBejkDauTH071YeP0QiGU0dLHzIfK1ECuFmpwSNZWhTS2NJShUo7Uqq/BcKbrk9FUpurizVixxlYLLNgVKXnUBrrFq9yNcIJYcKoU0dhEzFEejjKpdzPRqbKhdhjaKmOeFnNi7okHJGMhyebql9/xCzp/2XX3CC/nMnIMg8Iv8ZF2pQezjRwCMKkidgFvKa5bfr7jhNzo6Ojr+MW9SSWRWWBtShQAAAABJRU5ErkJggg==","orcid":"","institution":"CAP Almacelles, Atenció Primària, Gerència Territorial de Lleida, Institut Català de la Salut, 44, 25007 Lleida, Spain","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Marta","middleName":"Ortega","lastName":"Bravo","suffix":""}],"badges":[],"createdAt":"2024-06-13 08:25:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4574634/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4574634/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-025-02820-2","type":"published","date":"2025-04-28T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81988038,"identity":"d382f124-1540-43a8-a5ac-1951e24fe0bd","added_by":"auto","created_at":"2025-05-05 16:07:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1239137,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4574634/v1/a6f6b1ce-71a0-411b-81ad-44d52eaffde5.pdf"},{"id":59467291,"identity":"c35c3cc6-496d-430a-abfc-5f5d64f6c21a","added_by":"auto","created_at":"2024-07-02 06:52:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":112309,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4574634/v1/e457abe9af3e654f83938cb1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":" Vaccine refusal and hesitancy in Spain: an online cross-sectional questionnaire ","fulltext":[{"header":"Blackground","content":"\u003cp\u003eVaccination is a cost-effective public health measure that can prevent the spread of diseases and reduce the morbidity burden [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. High vaccine uptake leads to a decline in the prevalence of vaccine-preventable diseases (VPDs) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Vaccines are safe and effective and, although like medication they can cause adverse effects, these adverse effects are outweighed by individual and collective benefits [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy concluded that vaccination hesitancy refers to delay or refusal of vaccination despite the availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Declines in vaccination present threats to herd immunity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization (WHO), 1.5\u0026nbsp;million child deaths from VPDs occur every year worldwide This is partly due to problems of access to vaccines for socio-economic reasons, and partly to vaccination hesitancy generated by the rise of anti-vaccine movements [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Vaccination hesitancy is considered a priority line of action for the WHO and a challenge for those countries working to close the immunisation gap [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe SAGE Group noted that the Vaccine Hesitancy Determinants Matrix displays the factors influencing the behavioural decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine/vaccination-specific influences [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A publication analysing the psychological factors that might motivate people in 25 countries to refuse vaccination showed that the best predictors of refusal were the following: high levels of conspiracy beliefs, low tolerance of perceived infringement of personal freedom, aversion to needles or blood, and religious beliefs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Another review highlighted the complexity of factors related to acceptance or refusal of vaccines including demographic factors (ethnicity, age, sex, pregnancy, education, and employment), accessibility and cost of vaccines, personal responsibility and risk perceptions, trust in healthcare authorities and vaccines, safety and efficacy of new vaccines, and lack of information or misinformation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Spain, vaccination coverage is high but varies depending on the vaccine. Vaccination is offered by the national public health system, and most vaccines are provided free of charge and administered primarily in primary care settings, with minor differences between autonomous communities. Data published by the Spanish Ministry of Health in 2022 showed a slight increase from the previous year in primary vaccination coverage (Polio, DTaP, Hib, Hepatitis B, Meningococcus C, Pneumococcus), as evidenced by the percentage of the population receiving the second dose of the hexavalent vaccine (DTaP, Hib, Hepatitis B) increasing from 96.8% in 2021 to 97.6% in 2022. However, coverage of two doses of the Measles, Mumps, and Rubella (MMR) vaccine in 2022 was 92.6% which did not meet the target coverage of \u0026ge;\u0026thinsp;95% needed to keep measles\u0026rsquo; elimination status, even if coverage was achieved considering only one dose. After the positive effect of the COVID-19 pandemic on influenza vaccine coverage, there was a decreasing trend in influenza vaccine coverage in all population groups, while remaining higher than pre-pandemic levels [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVaccine hesitancy had been previously studied in Spain in specific groups such as HCPs and epidemiologists, so we consider it interesting to study it in the general population. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our study aimed to characterise the profile of the Spanish population with vaccination refusal specifically and hesitancy in general, to help HCPs conduct targeted vaccination campaigns to improve vaccination coverage. With this objective, we used an online questionnaire to describe the socio-demographic and sociocultural characteristics, beliefs and opinions of those refusing to have vaccine and those with hesitancy about vaccination, and their vaccination behaviours by vaccine type and sex.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eWe conducted an observational, cross-sectional study on individuals accessing an online survey from March to December 2021. The inclusion criteria required participants to be aged 18 years or older and to have the authority to make vaccination decisions for themselves or others in Spain.\u003c/p\u003e \u003cp\u003eWe obtained the information through an online, self-administered questionnaire designed by the project research team. A pilot test was performed before the definitive questionnaire was obtained. To ensure the rigor and validity of the study, an experienced research team with expertise in conducting surveys was involved, thereby guaranteeing the quality and reliability of the instrument. Both were registered on a Research Electronic Data Capture (REDCap) web platform stored on a centralized server where the data remain securely in the custody of the Institut Catal\u0026agrave; de la Salut [Catalan Institute of Health]. Anonymous information was exported to the statistical packages used for later analysis. The REDCap platform generated a link [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] for participation in the survey that was disseminated through scientific societies, social networks, research institutes, paediatricians, and nurses in primary care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eVariables\u003c/h2\u003e \u003cp\u003eThe main variables of the questionnaire were: sociodemographic factors (sex, age, having children under 15 years old, level of education); sociocultural factors ( religious beliefs, culture, family); vaccine information variables (whether they have refused any vaccines and, in that case, the type of vaccine refused; who the refused vaccine was for; hesitancy due to vaccine components, associated diseases or to the payment of vaccines; whether they know that personal vaccination protects other people whether they would be in favour of free and compulsory vaccination; opinion about vaccines), variables of trust in the health system (sources of information about vaccines, whether HCPs can understand anti-vaccine arguments, whether HCPs have enough information to satisfy anti-vaccine people, whether when in doubt about vaccines they will consult the HCP); habits (type of diet, consumption of cow's milk, opinion on breastfeeding or artificial breastfeeding, opinion on alternative treatments or complementary treatments).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were gathered in an anonymized database using the REDCap platform. We conducted a descriptive analysis of the findings, categorizing qualitative or ordinal data using absolute and relative frequencies. In the statistical analysis, only complete cases were considered, and missing values were assumed to be missing at random. We evaluated the relative frequency of the categorical variables using the Chi square test or Fisher's exact test and identified the variables that were both statistically significant and clinically relevant. In selected subgroups of interest, we identified the factors independently associated with these results. The relationship between the variables is quantified using Odds Ratios (ORs), with 95% confidence interval (CI) estimates, as a measure of association for risk. We used logistic regression to identify which factors are independently linked to vaccination refusal or to hesitancy due to vaccine components or diseases that have been associated to being vaccinated. We employed a stepwise conditional variable recall model that retains variables at an adjusted p-value of \u0026lt;\u0026thinsp;0.05 and excludes variables with a value\u0026thinsp;\u0026gt;\u0026thinsp;0.10. This included factors that were statistically significant in our initial comparisons of two variables at a time. We report the likelihood of these factors as ORs and their statistical significance (as adjusted p-values), using a cut-off of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 to define statistical significance. All analysis was conducted using SPSS software version 26.0.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the ethics and clinical Research Committee of the Fundaci\u0026oacute; Institut Universitari per a la Recerca a l'Atenci\u0026oacute; Prim\u0026agrave;ria de Salut Jordi Gol i Gurina (IDIAPJGol), with code 20/221-P. The study was conducted following the principles of the Declaration of Helsinki. The variables collected were treated anonymously to guarantee the confidentiality of the data, as established in Regulation (EU) 2016/679 of the European Parliament and the Council of April 27 on Data Protection (RGPD) and the Spanish Organic Law 3/2018, of the 5th December 2018, regarding the protection of personal data and guarantees of digital rights. The database is kept by the principal investigator and the research team in an Excel format, protected by password access. An anonymized database was used for the analysis. Before conducting the survey, online informed consent was completed, accepted, and signed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDescription of the study population and percentages of vaccine refusal and hesitancy (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1312\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e*Responders to Q25\u003c/p\u003e \u003cp\u003e n\u0026thinsp;=\u0026thinsp;1294\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eRefusers\u003c/p\u003e \u003cp\u003e n\u0026thinsp;=\u0026thinsp;218\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e326 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e325 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e53 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e954 (74.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e952 (74.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e163 (75.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (recodified):\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 years old or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e180 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e180 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e25 (11.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;59 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e948 (73.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e947 (73.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e151 (69.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60 years old or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e159 (12.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e157 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e40 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity studies:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e374 (29.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e372 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e58 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e915 (71.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e914 (71.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e159 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you have sons or daughters under 15 years old?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e604 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e603 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e106 (48.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e685 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e683 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e112 (51.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYour religious beliefs are:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn favour of vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e467 (35.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e466 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e51 (23.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgainst vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e2 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI have no opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e237 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e220 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e61 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am not a believer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e494 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e494 (38.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e92 (42.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e108 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e108 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e12 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYour culture is:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn favour of vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1111 (84.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1109 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e161 (73.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgainst vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14 (1.07%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e14 (1.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e9 (4.13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI have no opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e128 (9.76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e112 (8.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e36 (16.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e59 (4.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e59 (4.56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e12 (5.50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYour family is:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn favour of vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1165 (88.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1163 (89.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e164 (75.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgainst vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e32 (2.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e32 (2.47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e14 (6.42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas no opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e90 (6.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e74 (5.72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e31 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e25 (1.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e25 (1.93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e9 (4.13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOpinion about vaccinations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eN\u0026thinsp;=\u0026thinsp;1312\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003e*Responders to Q25\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e n\u0026thinsp;=\u0026thinsp;1294\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003eRefusers\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e n\u0026thinsp;=\u0026thinsp;218\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHave you ever refused a vaccine?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e218 (16.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e218 (16.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e218 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Diptheria)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (1.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (1.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (6.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Influenza)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135 (10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e135 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e135 (61.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Haemophilus influenzae type B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (0.61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (0.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (3.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Hepatitis A)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (1.37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (1.39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 (8.26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Hepatitis B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (2.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (2.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Meningococcus ACWY(Nimenrix\u0026reg;, Menveo\u0026reg;))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (1.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (1.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (6.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Meningococcus B (Bexero\u0026reg;, Trumemba\u0026reg;))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (1.37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (1.39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 (8.26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Meningococcus C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (0.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (0.93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (5.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Pneumococcus)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (1.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (1.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (6.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Polio)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (1.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (1.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (6.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Rotavirus (Rotarix \u0026reg;, Rotateq\u0026reg;))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (1.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (1.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (11.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Tetanus)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (3.05%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (3.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40 (18.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Whooping cough)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (1.07%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (1.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (6.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Triple v\u0026iacute;rica (MMR))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (1.68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (1.70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22 (10.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Papiloma virus HPV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (2.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (2.70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;Varicella)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (2.36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (2.40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhich vaccine have you refused? (choice\u0026thinsp;=\u0026thinsp;I do not remember)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (2.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (2.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of vaccines refused\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.37 (1.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37 (1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.21 (3.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWho was the vaccine for? (choice\u0026thinsp;=\u0026thinsp;My sons and/or daughters)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (5.72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75 (5.80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75 (34.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWho was the vaccine for? (choice\u0026thinsp;=\u0026thinsp;My mum or dad)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (0.61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (0.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (3.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWho was the vaccine for? (choice\u0026thinsp;=\u0026thinsp;Me)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e160 (12.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e160 (73.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWho was the vaccine for? (choice\u0026thinsp;=\u0026thinsp;Others (open))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (0.61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (0.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (3.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas the fact that vaccines contain components like thiomersal, aluminium, mercury or formaldehyde caused you any doubts about vaccines?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e362 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e359 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e99 (45.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas the fact that vaccines have been linked to diseases such as cancer, allergies, autism, sudden infant death syndrome, multiple sclerosis, asthma, and alterations of the immune system caused you any doubts about vaccines?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e399 (30.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e398 (30.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e101 (46.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas the fact that you have to pay for any of the vaccines caused you any doubts about vaccination?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e374 (29.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e373 (29.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e68 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you agree with vaccines:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotally agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e982 (76.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e982 (76.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e112 (52.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e215 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndifferent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (2.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (2.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (6.07%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (3.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (3.34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 (8.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotally disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (1.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (1.24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (5.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u0026sup1;Responded to the question of whether they had ever refused a vaccine\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eSum of percentages might be slightly different from 100 because of roundings.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was a total of 1312 respondents to the survey: 74.5% were females and 25.5% males; 14.0% were under 31 years old, 73.7% between 31\u0026ndash;59, and 12.4% over 59. Out of all the respondents, 1294 responded to the question of whether they had ever refused a vaccine, with 16.8% (218/1294) of these claiming to have indeed refused vaccines.\u003c/p\u003e \u003cp\u003eOf the 218 respondents who had refused vaccines, the most commonly refused vaccine was for influenza (61.9%) followed by tetanus (18.3%) and papilloma (HPV) (16.1%). Other vaccines refused included the following: chicken pox (14.2%); hepatitis B (12.8%); MMR (10.1%); hepatitis A (8.3%); and diphtheria, pneumococcus, and polio (each 6.9%). A small proportion declined the vaccine for pertussis (6.4%), meningococcus C (5.5%), and haemophilus influenzae type B (3.7%). A percentage of 17.0% of respondents who had refused vaccines could not remember which vaccine they refused and 5.5% did not specify. Among the vaccines not funded by Spanish Health System in 2019, refusal rates were 11.0% for rotavirus, 8.3% for Meningococcus B, and 6.9% for Meningococcus ACWY. Of those who had refused vaccines, the majority (66%) had refused just one vaccine, while 34% had refused two or more. Most (73.4%) had refused vaccines for themselves, while some (34.4%) for their children, and just a few (3.7%) for their parents or others.\u003c/p\u003e \u003cp\u003eHesitancy due to vaccine components was cited by 28.1% of respondents, associations with disease that have been linked to vaccines by 30.9%, and the fact that some vaccines must be paid for by 29.0%.\u003c/p\u003e \u003cp\u003eWhen looking at the overall support respondents showed for vaccines, a significant majority (76.1%) expressed strong support for vaccines, 16.7% showed slight agreement, and only a small fraction expressed indifference, or a slight or strong disagreement to vaccines (2.4%, 3.4%, and 1.3% respectively).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic and sociocultural characteristics, beliefs, and opinions of the population who refused vaccines\u003c/h2\u003e \u003cp\u003eWe observed a significant positive association between vaccination refusal, being 60 years old or older, and with anti-vaccination culture and family (Table A1). There was also an association between refusing vaccination and hesitancy due to the vaccine components or associated diseases, a lack of understanding of the community-wide protection benefits of individual vaccination, and a reluctance to support compulsory vaccination even if it was free. Respondents who had refused vaccination were less inclined to view HCPs and healthcare websites as reliable sources of vaccine information than those who had not refused vaccination, and they trusted more friends. Moreover, respondents who had refused vaccination felt that HCPs lacked the information to address anti-vaccine hesitancy and would not consult HCPs, if they had a vaccine question. Finally, vaccination refusal, apart from being strongly related to total disagreement with vaccines, was also strongly related to opposition to the use of infant formula, or consumption of cow's milk, and support of alternative medicine. (Table A2).\u003c/p\u003e \u003cp\u003eIn our multivariate logistic regression analysis, we found a statistically significant independent association between refusal of vaccination with the following variables: being 60 years and older; having hesitancy due to vaccine components; being against mandatory and free vaccination; not knowing that vaccination protects the community; and being against consuming cow\u0026rsquo;s milk and the use of infant formulas for breastfeeding (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDependent variable: Refusal of vaccination\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant independent variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI OR inf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI OR sup\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 years old or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;59 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0,001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60 years old or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge of protecting more people\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.754\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesire for free and compulsory vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHesitancy due to vaccine components\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpinion on use of infant formula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.454\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpinion on consumption of cow\u0026rsquo;s milk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.929\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSocio-demographic and sociocultural characteristics, beliefs and opinions of the population with hesitancy due to vaccine components, associated diseases, or payment\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWomen, parents with children under 15 years old and individuals with a culture or family against vaccination were more likely to express hesitancy due to vaccine components. Also, a heightened frequency of hesitancy due to the diseases associated with vaccines was seen among certain groups. In particular, individuals under 30 years old, women, those without a university education, those with children under 15 years old, and those aligned with a culture or family against vaccination (Table A1).\u003c/p\u003e \u003cp\u003eIndividuals expressing hesitancy due to vaccine components (Table A3) or associated diseases (Table A4) were more hesitant about the payment for vaccines, were more likely unaware that individual vaccination protects the community and less likely to be in favour of free and compulsory vaccination. As for their information sources, they were more likely to report that social networks, family, and friends were reliable sources of information about vaccines. Conversely, they expressed more distrust in HCPs, and believed that HCPs are not a reliable source of information to satisfy anti-vaccine sentiments and would not consult an HCP if they had a question. There was greater hesitancy due to vaccine components or associated diseases among respondents who disagreed with vaccines, infant formula milks, cow's milk consumption or who had diets other than the Mediterranean diet and favoured alternative and complementary treatments (Table A3 and A4).\u003c/p\u003e \u003cp\u003eIn our multivariate logistic regression analysis, we found a statistically significant independent association between hesitancy due to vaccine components or associated diseases with individuals under 30 years old, women, those with children under 15 years old, individuals against free and compulsory vaccination, those unaware of the community protection aspect of vaccination, individuals with hesitancy about vaccine payment or with anti-vaccine attitudes, and in favour of alternative and complementary treatments (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDependent variable: Hesitancy due to vaccine components or associated diseases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant independent variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95%CI OR Inf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI OR Sup\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 years old or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;59 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.454\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60 years old or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (binary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.494\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChildren under 15 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.669\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.891\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge of protecting more people\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.864\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesire for free and compulsory vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHesitancy due to payment for a vaccine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpinion on vaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.637\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of alternative treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of complementary treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.549\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was more hesitancy due to the payment of vaccines among people younger than 30 years old, people without a university degree, and parents with children younger than 15 years old (Table A1). Those who were not in favour of free and compulsory vaccination, who were more likely to consider friends as reliable sources of information on vaccines, were also more likely to have hesitancy due to the payment of vaccines. People with hesitancy about vaccine payment reported that HCPs did not have enough information to satisfy people with anti-vaccine concerns. They also reported that they disagreed more with vaccines, the use of infant formula, and the consumption of cow's milk, and more of them were in favour of alternative treatments (Table A5)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eVaccination behaviours by vaccine type and sex\u003c/h2\u003e \u003cp\u003eThe socio-demographic features associated with various vaccines types mirrored the overall profile of vaccine refusal, albeit with some nuanced distinctions. Notably, individuals aged 60 years or older exhibited a higher refusal of influenza and tetanus vaccines. Men displayed a greater tendency to refuse tetanus vaccines, while university students showed a higher refusal to rotavirus vaccines but a lower refusal to tetanus vaccines. Parents with children under 15 years old display a higher refusal of vaccines for Haemophilus influenzae type B, Meningococcal B, and Rotavirus (Table A6).\u003c/p\u003e \u003cp\u003eMen showed a higher refusal rate for tetanus vaccination, whereas women demonstrated a greater inclination to refuse vaccines for their children (Table A7). Additionally, women, particularly those without children under 15 years old showed more hesitancy due to vaccine components or associated diseases (Table A8).\u003c/p\u003e \u003cp\u003eRegarding vaccine information sources, there were no discernible sex differences in the perceived reliability of HCPs, family or friends. However, women tended to view health websites as more reliable, while men leaned towards social networks, television and radio. Moreover, a larger proportion of men strongly disagreed with vaccines, in comparison with women. Finally, women showed a stronger preference for complementary treatments, although no sex differences were seen regarding alternative treatments (Table A7).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, we found that respondents generally favored vaccination, with a refusal prevalence of 16.8%. This rate aligns with published data on the intention to refuse the COVID-19 vaccine in the Catalan population during the same year as the study. This indicates that the vaccine hesitancy observed in our sample is consistent with broader regional trends. Additionally, within this inquiry, we detected an increase in doubts about vaccines as a result of the pandemic [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which mirrors global trends of heightened vaccine skepticism fueled by misinformation and rapidly evolving scientific guidelines during the COVID-19 crisis.\u003c/p\u003e \u003cp\u003eAlthough official data regarding vaccine rejection are not at our disposal, we do have authoritative records delineating vaccine acceptance trends. These records evince that vaccination coverage rates in Spain for the years 2021 and 2023 remained comparably stable. Notably, in 2024, a marginal augmentation in vaccination coverage for MMR and hexavalent vaccines was observed. This suggests a positive trend in the uptake of these essential vaccines, possibly due to public health campaigns and increasing public awareness of the benefits of vaccination. However, this positive trend was contrasted by a diminished coverage for influenza compared to the year 2021 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, we believe the data on hesitancy and refusal of vaccination could be valuable in the current scenario of vaccination in Spain in 2024, as it highlights areas needing targeted interventions to improve vaccine uptake and address ongoing public concerns about vaccine safety and efficacy\u003c/p\u003e \u003cp\u003eThe SAGE Vaccine Hesitancy Working Group categorize vaccine hesitancy using a matrix of contextual influences, individual/social influences, and vaccine and vaccination specific issues [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study delved into several contextual influences, particularly focusing on the sociodemographic and sociocultural characteristics of the population. Analysis of respondent age revealed higher rates of vaccine refusal among those over 60 years old. This does not coincide with previous findings from other studies, where a greater likelihood of vaccination was detected in older people because of increased health concerns and susceptibility to illness [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. We believe that the reason for this finding may stem from the significant rejection in our older population of the influenza vaccination, which is primarily targeted at people over 65 years old or with underlying pathologies in Spain, and from the difficulties already described in previous publications to achieve satisfactory vaccination coverage against influenza [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. We also detected greater hesitancy among people under 30 years old, particularly due to concerns about diseases associated with vaccines and the cost of vaccines. This finding is consistent with previously published studies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and underscores the need for vaccination campaigns tailored to specific age groups, addressing their unique concerns and barriers.\u003c/p\u003e \u003cp\u003eWhen considering sex, our study revealed that women and parents with children under 15 years old, showed greater hesitancy due to the components of vaccines or diseases that have been associated with vaccines. Greater doubts were detected in women without children under 15 years old than in men. Moreover, women were more likely to refuse vaccines for their children, aligning with previous studies, which show a greater predisposition to vaccination in men than in women, and less acceptance and greater hesitancy in parents [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Concretely, women with young children are more concerned about vaccinating their children, necessitating targeted strategies to bolster the trust and confidence, as previously proposed [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding education level, individuals without a university education exhibited greater hesitancy due to associated diseases or vaccine payment. This aligns with published studies that show that the higher the level of education, the greater the acceptance of vaccines [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCultural, religious, and family beliefs emerged as influential factors associated with hesitancy and decision about vaccination, with a greater predisposition to get vaccinated if the sociocultural environment is provaccine. These results echo findings from prior studies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn terms of political and policy-related contextual influences, most respondents favoured free and compulsory vaccination, except those who refused vaccines or expressed hesitation because of components, associated diseases, or payment for vaccines. Although in recent years there has been growing traction for anti-vaccine movements, most of the population seems to be in favour of compulsory vaccination policies, as evidenced in a 2019 review. Moreover, it seems that support towards mandatory policies increases after their implementation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Nonetheless, efforts to improve vaccine acceptance, such as enhancing education and providing proof of the efficacy, benefits and safety of vaccines, remain crucial [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe observed greater vaccine refusal and hesitancy among individuals who deemed health professionals or websites unreliable sources of vaccine information, while considering friends, family, or social networks as reliable sources. These results reinforce previous publications which stated that the crisis in the vaccination system and the resurgence of anti-vaccine movements are due to the increased accessibility of information and the reduced credibility of HCPs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Exposure to anti-vaccine content on social media was associated with refusal and hesitancy to vaccinate [\u003cspan additionalcitationids=\"CR34 CR35 CR36\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], highlighting the critical need to combat misinformation to mitigate its effects [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study also suggests that a lack of trust in HCPs is associated with greater vaccine refusal and hesitancy. This aligns with existing reviews and published studies that conclude that vaccine safety and trust in health authorities are the main factors in promoting vaccine acceptance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. According to the WHO's \"3Cs\" model (confidence, compliance, convenience), confidence in vaccines and in the healthcare system constitute one of the three main determinants of vaccine hesitancy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe detected a greater refusal of the vaccines for influenza, tetanus, papilloma, and varicella (chicken pox). Mostly individuals refused vaccines for themselves and, to a lesser extent, their children. These findings mirror other international studies which highlight the difficulties in achieving satisfactory vaccination coverage for influenza and papillomavirus [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Data published by the Spanish Ministry of Health also corroborate these difficulties in vaccination coverage for influenza, papilloma, and varicella in 2021\u0026ndash;2022. In Spain, the recommendation to maintain vaccination coverage\u0026thinsp;\u0026ge;\u0026thinsp;95% for MMR vaccination in 2021\u0026ndash;2022 was not achieved [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the goal of maintaining measles and rubella elimination status was not met [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Again, although there are high coverage rates for tetanus in primary vaccination with the hexavalent vaccine, vaccination coverage with Td decreases in adolescents [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our study, we found a greater refusal of tetanus vaccine than the diphtheria vaccine, although tetanus and diphtheria vaccines are usually administered together. We attribute this difference and other similar ones to a possible lack of knowledge of the vaccination schedule in our reference population or to a greater popular knowledge of tetanus vaccine because of its indication for administration in certain wounds.\u003c/p\u003e \u003cp\u003eOur study revealed a relationship between having hesitancy due to vaccine components and refusing a vaccine. It also showed that having hesitancy due to vaccine components or associated diseases were associated with hesitancy due to vaccine payment. Earlier research has found that accessibility and cost, along with safety and efficacy were reasons for hesitancy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In most Spanish autonomous communities, the Meningococcal ACWY and Meningococcal B vaccines are now part of the public vaccination schedule and thus should no longer be a reason for hesitancy because of costs in these cases [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollective responsibility was assessed and greater refusal and hesitancy was detected in respondents who were unaware that individual vaccination protects the community. The concept of collective responsibility was one of five factors that affect people\u0026rsquo;s perception of vaccines, along with confidence (trust in vaccine efficacy and safety), complacency (perception about the risk of the disease), calculation (weighing the risks and benefits of vaccines) and constraint (accessibility of information about the vaccine). These are part of the 5Cs model [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], which extends from the 3C model introduced by the WHO SAGE Working group [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe intended to study the profile of the local population with vaccine hesitancy and we observed heightened hesitancy among people who disagreed with cow's milk consumption or the use of infant milk formulas, and those who adhered to a non-Mediterranean diet or favoured alternative or complementary treatments for healthcare. This profile of a population with a preference for natural therapies, skepticism towards established scientific positions, and greater reticence towards healthcare systems and HCPs, seems to be the profile of vaccine hesitancy detected in primary care. In another study published in the UK in the same year, rejection and hesitancy towards vaccination were also associated with low confidence in the health service [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To address vaccine hesitancy, we urge institutions and governmental bodies to seek strategies to enhance trust in HCPs, public health systems, authorities, and health policies. Encouraging shared participation in the formulation of vaccine recommendations is paramount [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Additionally, as previously suggested by some authors, novel approaches such as analysing population opinions on vaccination through social networks using artificial intelligence to complement traditional survey methods, can provide a more comprehensive understanding of vaccine refusal and hesitancy dynamics and allow targeted interventions. Such initiatives can facilitate effective engagement with diverse communities and foster informed decision-making regarding vaccination [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR44 CR45\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the limitations of this study is the inherent recruitment bias associated with the online survey method, which restricted participation to individuals with internet access. This can produce selection bias problems because there are different probabilities of being involved in the study depending on where people live, their level of education, and their age. Therefore, this may hinder the generalization of the results. However, given that 96.1% of Spanish households have internet access and 85% of Spaniards are users of social networks [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], the reach of our survey remains substantial. Another possible limitation is potential respondent repetition, although, we anticipate minimal impact on the final results because of expected low rate of repetition. Additionally, our sample skewed towards women and people with a university education, this could limit the interpretation and generalization of our study to the broader population. Finally, reaching the anti-vaccine population posed challenges, as interactions with these groups is difficult. To mitigate eventual bias deriving from this, in our sample size calculation, we considered that the proportion of antivaccine responses would be much lower than the proportion of pro-vaccine responses. Despite these limitations, our study provides valuable insights into vaccine refusal and hesitancy, but caution is warranted in extrapolating findings to the entire population.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eVaccination refusal in our surveyed population was low and mainly related to refusal of influenza vaccination, although hesitancy arguments related to vaccine safety were detected, which could compromise vaccination coverage.\u003c/p\u003e \u003cp\u003eVaccine refusal was mainly associated with individuals over 60 years old, characterized by hesitancy towards vaccine components, a resistance to compulsory vaccination, and a lack of awareness regarding vaccination\u0026rsquo;s community-wide protection benefits. Furthermore, resistance extended to dietary choices, notably being against cow's milk and the use of infant formulas for breastfeeding.\u003c/p\u003e \u003cp\u003eVaccine hesitancy, on the other hand, was mainly associated with a younger demographic of people under 30 years old, typically women, parents of young children under 15 years old, and against compulsory vaccination. They were generally also unaware that vaccination protects the community, with hesitancy about vaccine payment or with anti-vaccine attitudes, and in favour of alternative and complementary treatments.\u003c/p\u003e \u003cp\u003eIn general, greater hesitancy to vaccination was detected in women and they reported a greater refusal to vaccinate their children than men.\u003c/p\u003e \u003cp\u003eAddressing these complexities requires proactive health policies aimed at strengthening trust in scientific positions and HCPs. Additionally, strategies must be tailored to enhance community engagement and ensure sufficient education regarding vaccination, especially among populations with lingering doubts. Multifaceted approaches are indispensable for navigating the intricacies of vaccine acceptance and safeguarding public health in the face of evolving challenges and threats to established progress made at reducing vaccine refusal and hesitancy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVPDs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Vaccine-preventable Diseases\u003c/p\u003e\n\u003cp\u003eSAGE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Strategic Advisory Group of Experts\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;World Health Organization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDTaP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Diphtheria, Tetanus, Pertussis\u003c/p\u003e\n\u003cp\u003eMMR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Measles, Mumps, and Rubella\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCPs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Healthcare professionals\u003c/p\u003e\n\u003cp\u003eREDCap \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Research Electronic Data Capture\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics and Clinical Research Committee of the\u0026nbsp;Fundaci\u0026oacute; Institut Universitari per a la recerca a l\u0026apos;Atenci\u0026oacute; Prim\u0026agrave;ria de Salut Jordi Gol i Gurina (IDIAPJGol), with code 20/221-P. The study was conducted following the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all the subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are hosted on the research team\u0026apos;s internal servers and will be provided under reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Ajuts a Projectes en Projectes en Recerca en Atenci\u0026oacute; Prim\u0026agrave;ria-Diputaci\u0026oacute; Lleida 2021-1a Edici\u0026oacute; (Ajut PICARD) modalitat projecte (4R22/152) y modalitat publicaci\u0026oacute; i traducci\u0026oacute; d\u0026apos;articles (9F22/017) and \u0026nbsp;by BECA AEPap-FPS 2020 for research in Primary Care Paediatrics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAH-F, EA-B, MO-B contributed to the study concept and research design, selected, and reviewed the literature on vaccination. JS and XG-A participated in the acquisition, analysis, and interpretation of data. AH-F, EA-B, MO-B, JS, XG-A and PG participated in the writing and critical review of the manuscript and approved the final version. AH-F and Group MC-MUVA contributed to the recruitment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection would not have been possible without the collaboration of the MC- MUVA work group, the Xarxa de Recerca en Pediatria d\u0026apos;Atenci\u0026oacute; Prim\u0026agrave;ria [Research Network of Primary Care Paediatrics], and the Societat Catalana de Pediatria [Catalan Society of Paediatrics]. Our special thanks go to the dedicated investigators and participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMC-MUVA work group: Rebecca Oglesby, Merce Font Arb\u0026oacute;, Lidia Sanz Borrell, Mireia Biosca P\u0026agrave;mies, Marta Pifarre Ortiz, Sara Mart\u0026iacute; Mart\u0026iacute;, Daniel Gros Esteban, Laura Guix Cliville, Noelia Diaz Charles, Silvia Prado Mu\u0026ntilde;oz, Susana Perez Osuna, Merc\u0026egrave; Giribet Folch, Magda Riera Veciana, Carles Gatius Tonda, Laura Seoane Barbosa, Pilar Serra Solans, M\u0026iacute;riam Poblet, M. Jos\u0026eacute; Casta\u0026ntilde; Castillo, Elena Alcover Bloch, Anna Castan, Magda Barber\u0026agrave; Farr\u0026eacute;, Sara Serra Font, M\u0026ograve;nica Martinez, Imma Caubet Busquet, Maria Planella Cornudella, Gema Terrer Manrique, Raul Morales, Anna Gatell Carbo, Carme Farran Balcells,Carmen G\u0026oacute;mez Seara, Viktoriya Atroshchenko Shushko, Margaret Creus Verni, Veronida M\u0026ordf; Karcz, Judith Palacin Aguil\u0026agrave;, Joana Garcia Hinojosa, Mihaela Cozar, Rosa Aran Padull\u0026eacute;s, Ram\u0026oacute;n Capdevila Bert,Montse Crespo Pons, Maria Jose Lara Tostado, Isabel Segarra Solanes, Enmanuel Aneudi Estevez Genao, Raquel Plasencia Atienza, Maria Chin\u0026eacute; Segura, Meritxell Pelegr\u0026iacute; Romeo, Montse Farran Jov\u0026eacute;, Carme Trilla Felis, Rub\u0026eacute;n Lopez Ruiz, Iratxe Olabegoya Estrela, Roser Racero Maire, Sonia Asensio, Merce Lozano Vergara, Merc\u0026egrave; Cort\u0026eacute;s Llad\u0026oacute;, \u0026Agrave;ngels Font Anglada, Sara Borrat Padrosa, Maria Payan Sala, B\u0026aacute;rbara Montilla Cabrera, Samanta Barisonzi Zambrano, Almudena Sanchez, Cristina Casademont, Pyrene Martinez, Anna M. Ristol Perx\u0026eacute;s, Irene G\u0026oacute;mez i P\u0026eacute;rez, Jaume Miquel Salsas.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOMS. Vacunas e inmunizaci\u0026oacute;n: la seguridad de las vacunas. 2020 [accessed 2023-11-26]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/es/news-room/questions-and-answers/item/vaccines-and-immunization-vaccine-safety\u003c/span\u003e\u003cspan address=\"https://www.who.int/es/news-room/questions-and-answers/item/vaccines-and-immunization-vaccine-safety\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen C, Yang Q, Tian H, Wu J, Chen L, Ji Z, et al. Bibliometric and visual analysis of vaccination hesitancy research from 2013 to 2022. Hum Vaccin Immunother. 2023;19(2):2226584.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwingle CA. How Do We Approach Anti-Vaccination Attitudes? Mo Med. 2018;115(3):180\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeeting of the Strategic Advisory Group of Experts on immunization. October 2017 \u0026ndash; conclusions and recommendations. Wkly Epidemiol Rec. 2017;92(48):729\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018;10(7):e2919.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTafuri S, Gallone MS, Cappelli MG, Martinelli D, Prato R, Germinario C. Addressing the anti-vaccination movement and the role of HCWs. Vaccine. 2014;32(38):4860\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOMS. Diez cuestiones de salud que la OMS abordar\u0026aacute; este a\u0026ntilde;o. 2019 [Accessed 20 May 2020]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/es/news-room/spotlight/ten-threats-to-global-health-in-2019\u003c/span\u003e\u003cspan address=\"https://www.who.int/es/news-room/spotlight/ten-threats-to-global-health-in-2019\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOzawa S, Yemeke TT, Evans DR, Pallas SE, Wallace AS, Lee BY. Defining hard-to-reach populations for vaccination. Vaccine. 2019;37(37):5525\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHornsey MJ, Harris EA, Fielding KS. The psychological roots of anti-vaccination attitudes: A 24-nation investigation. Health Psychol. 2018;37(4):307\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTruong J, Bakshi S, Wasim A, Ahmad M, Majid U. What factors promote vaccine hesitancy or acceptance during pandemics? A systematic review and thematic analysis. Health Promot Int. 2022;37(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVacunas y Programa de Vacunaci\u0026oacute;n. Coberturas de Vacunaci\u0026oacute;n. Datos Estad\u0026iacute;sticos. Ministerio de Sanidad. Gobierno de Espa\u0026ntilde;a.2023 [accessed 2024-01-07]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/calendario-y-coberturas/coberturas/home.htm\u003c/span\u003e\u003cspan address=\"https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/calendario-y-coberturas/coberturas/home.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePicchio CA, Carrasco MG, Sagu\u0026eacute;-Vilavella M, Rius C. Knowledge, attitudes and beliefs about vaccination in primary healthcare workers involved in the administration of systematic childhood vaccines, Barcelona, 2016/17. Euro Surveill. 2019;24(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaballero P, Astray J, Dom\u0026iacute;nguez \u0026Aacute;, Godoy P, Barrabeig I, Castilla J, et al. [Validation of the questionnaire on vaccines and hesitancy to be vaccinated in the Spanish Society of Epidemiology]. Gac Sanit. 2023;37:102329.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIDIAP JordiGol. REDCap. [accessed 2023-02-06]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://redcap.link/uj4jozhy\u003c/span\u003e\u003cspan address=\"https://redcap.link/uj4jozhy\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuguet-Feixa A, Artigues-Barber\u0026agrave; E, Sol J, Godoy P, Ortega Bravo M. Effects of the COVID-19 Pandemic on the Decision and Doubts About Vaccination in Catalonia: Online Cross-sectional Questionnaire. JMIR Form Res. 2023;7:e41799.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarson HJ, Jarrett C, Schulz WS, Chaudhuri M, Zhou Y, Dube E, et al. Measuring vaccine hesitancy: The development of a survey tool. Vaccine. 2015;33(34):4165\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoshi A, Kaur M, Kaur R, Grover A, Nash D, El-Mohandes A. Predictors of COVID-19 Vaccine Acceptance, Intention, and Hesitancy: A Scoping Review. Front Public Health. 2021;9:698111.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagneux-Brunon A, Detoc M, Bruel S, Tardy B, Rozaire O, Frappe P, et al. Intention to get vaccinations against COVID-19 in French healthcare workers during the first pandemic wave: a cross-sectional survey. J Hosp Infect. 2021;108:168\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTroiano G, Nardi A. Vaccine hesitancy in the era of COVID-19. Public Health. 2021;194:245\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026ouml;nnerstrand B. Social capital and immunisation against the 2009 A(H1N1) pandemic in Sweden. Scand J Public Health. 2013;41(8):853\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMesch GS, Schwirian KP. Social and political determinants of vaccine hesitancy: Lessons learned from the H1N1 pandemic of 2009\u0026ndash;2010. Am J Infect Control. 2015;43(11):1161\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eB\u0026ouml;rjesson M, Enander A. Perceptions and sociodemographic factors influencing vaccination uptake and precautionary behaviours in response to the A/H1N1 influenza in Sweden. Scand J Public Health. 2014;42(2):215\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrante G, Baldissera S, Moghadam PF, Carrozzi G, Trinito MO, Salmaso S. Surveillance of perceptions, knowledge, attitudes and behaviors of the Italian adult population (18\u0026ndash;69 years) during the 2009\u0026ndash;2010 A/H1N1 influenza pandemic. Eur J Epidemiol. 2011;26(3):211\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoares P, Rocha JV, Moniz M, Gama A, Laires PA, Pedro AR et al. Factors Associated with COVID-19 Vaccine Hesitancy. Vaccines (Basel). 2021;9(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamnjanović K, Graeber J, Ilić S, Lam WY, Lep Ž, Morales S, et al. Parental Decision-Making on Childhood Vaccination. Front Psychol. 2018;9:735.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust. Pediatrics. 2006;117(5):1532\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHilton S, Smith E. Public views of the UK media and government reaction to the 2009 swine flu pandemic. BMC Public Health. 2010;10:697.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyers LB, Goodwin R. Determinants of adults' intention to vaccinate against pandemic swine flu. BMC Public Health. 2011;11(1):15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeale H, Leask J, Macintyre CR. Awareness, attitudes and behavior of hospital healthcare workers towards a mandatory vaccination directive: two years on. Vaccine. 2011;29(21):3734\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGualano MR, Olivero E, Voglino G, Corezzi M, Rossello P, Vicentini C, et al. Knowledge, attitudes and beliefs towards compulsory vaccination: a systematic review. Hum Vaccin Immunother. 2019;15(4):918\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarson HJ, Schulz WS. Reverse global vaccine dissent. Science. 2019;364(6436):105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMargolis MA, Brewer NT, Shah PD, Calo WA, Gilkey MB. Stories about HPV vaccine in social media, traditional media, and conversations. Prev Med. 2019;118:251\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArgyris YA, Monu K, Tan PN, Aarts C, Jiang F, Wiseley KA. Using Machine Learning to Compare Provaccine and Antivaccine Discourse Among the Public on Social Media: Algorithm Development Study. JMIR Public Health Surveill. 2021;7(6):e23105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBadur S, Ota M, \u0026Ouml;zt\u0026uuml;rk S, Adegbola R, Dutta A. Vaccine confidence: the keys to restoring trust. Hum Vaccin Immunother. 2020;16(5):1007\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn AG, Surian D, Leask J, Dey A, Mandl KD, Coiera E. Mapping information exposure on social media to explain differences in HPV vaccine coverage in the United States. Vaccine. 2017;35(23):3033\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurki T. The online anti-vaccine movement in the age of COVID-19. Lancet Digit Health. 2020;2(10):e504\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaterson P, Meurice F, Stanberry LR, Glismann S, Rosenthal SL, Larson HJ. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34(52):6700\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed N, Quinn SC, Hancock GR, Freimuth VS, Jamison A. Social media use and influenza vaccine uptake among White and African American adults. Vaccine. 2018;36(49):7556\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlan estrat\u0026eacute;gico para la eliminaci\u0026oacute;n del sarampi\u0026oacute;n y. la rubeola en Espa\u0026ntilde;a 2021\u0026ndash;2025: Ministerio de Sanidad. Gobierno de Espa\u0026ntilde;a; 2021 [accessed 2024-01-19]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.sanidad.gob.es/areas/promocionPrevencion/vacunaciones/sarampion-rubeola/docs/PlanEstrategico_SarampionyRubeola.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBetsch C, Schmid P, Heinemeier D, Korn L, Holtmann C, B\u0026ouml;hm R. Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination. PLoS ONE. 2018;13(12):e0208601.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVacunas y Programa de Vacunaci\u0026oacute;n. Calendarios de vacunaci\u0026oacute;n en las Comunidades Aut\u0026oacute;nomas.: Ministerio de Sanidad. Gobierno de Espa\u0026ntilde;a.; 2023 [accessed 2023-01-07]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ettps://www.sanidad.gob.es/areas/promocionPrevencion/vacunaciones/calendario-y-coberturas/calendario/Calendario_CCAA.htm\u003c/span\u003e\u003cspan address=\"http://ttps://www.sanidad.gob.es/areas/promocionPrevencion/vacunaciones/calendario-y-coberturas/calendario/Calendario_CCAA.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussain A, Tahir A, Hussain Z, Sheikh Z, Gogate M, Dashtipour K, et al. Artificial Intelligence-Enabled Analysis of Public Attitudes on Facebook and Twitter Toward COVID-19 Vaccines in the United Kingdom and the United States: Observational Study. J Med Internet Res. 2021;23(4):e26627.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwok SWH, Vadde SK, Wang G. Tweet Topics and Sentiments Relating to COVID-19 Vaccination Among Australian Twitter Users: Machine Learning Analysis. J Med Internet Res. 2021;23(5):e26953.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTo QG, To KG, Huynh VN, Nguyen NT, Ngo DT, Alley S, et al. Anti-vaccination attitude trends during the COVID-19 pandemic: A machine learning-based analysis of tweets. Digit Health. 2023;9:20552076231158033.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed W, Vidal-Alaball J, Vilaseca JM. A Social Network Analysis of Twitter Data Related to Blood Clots and Vaccines. Int J Environ Res Public Health. 2022;19(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIdescat. Llars amb acc\u0026eacute;s a Internet: Institut d'Estad\u0026iacute;stica de Catalunya; 2022 [Accessed 28 Nov 2023]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.idescat.cat/indicadors/?id=ue\u0026amp;n=10144\u003c/span\u003e\u003cspan address=\"https://www.idescat.cat/indicadors/?id=ue\u0026amp;n=10144\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStatista. Penetraci\u0026oacute;n de las redes sociales en Espa\u0026ntilde;a de 2010 a 2023 2023 [Accessed 28 Nov 2023]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://es.statista.com/estadisticas/910163/redes-sociales-porcentaje-de-usuarios-por-comunidad-autonoma-en-espana/\u003c/span\u003e\u003cspan address=\"https://es.statista.com/estadisticas/910163/redes-sociales-porcentaje-de-usuarios-por-comunidad-autonoma-en-espana/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"anti-vaccination movement, anti-vaccine, vaccination refusal, vaccine hesitancy","lastPublishedDoi":"10.21203/rs.3.rs-4574634/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4574634/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBlackground\u003c/h2\u003e \u003cp\u003eVaccine refusal and hesitancy pose a critical challenge to public health, leading to delays in vaccination and compromising herd immunity.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eTo address this issue, we conducted a comprehensive observational study on the adult Spanish population in 2021. Through an online questionnaire, we explored the sociodemographic and sociocultural factors, beliefs, and opinions of those refusing or holding hesitancy about vaccines, and their vaccination behaviours by vaccine type and sex.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were 1,312 respondents: 74.5% were female, 73.7% were between 31 and 59 years old, and 71.0% had university studies. Our findings revealed that vaccine refusal rates were relatively low (16.8%), and mainly associated with influenza vaccination (10.3%). Greater refusal of vaccination was observed in over 60 years old, in those expressing hesitancy due to vaccine components and opposing free and compulsory vaccination, unaware that vaccination protects the community and being against consuming cow\u0026rsquo;s milk and the use of infant formulas for breastfeeding. Vaccine hesitancy was greatest in individuals under 31 years old, women, parents of children under 15 years old, against compulsory vaccination, unaware that vaccination protects the community, with hesitancy due to vaccine costs, and in favour of alternative and complementary treatments.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThese insights underscore the need for strategies to improve education about vaccination and dispel misconceptions are crucial for effectively reducing vaccine refusal and hesitancy across the population.\u003c/p\u003e","manuscriptTitle":" Vaccine refusal and hesitancy in Spain: an online cross-sectional questionnaire ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-02 06:52:52","doi":"10.21203/rs.3.rs-4574634/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-19T05:52:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-16T14:20:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-16T14:19:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-06-13T08:24:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f57e7c33-2490-4a93-9e55-7701a485c481","owner":[],"postedDate":"July 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T16:05:05+00:00","versionOfRecord":{"articleIdentity":"rs-4574634","link":"https://doi.org/10.1186/s12875-025-02820-2","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-04-28 15:57:21","publishedOnDateReadable":"April 28th, 2025"},"versionCreatedAt":"2024-07-02 06:52:52","video":"","vorDoi":"10.1186/s12875-025-02820-2","vorDoiUrl":"https://doi.org/10.1186/s12875-025-02820-2","workflowStages":[]},"version":"v1","identity":"rs-4574634","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4574634","identity":"rs-4574634","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}