Gereç ve Yöntem: Bu çalışmanın evreni Elazığ ilinde yaşayan Suriyeli göçmenlerden oluşmaktadır. Verilerin medyan (minimum-maksimum) değerleri verilmiş ve istatistiksel değerlendirmelerde Mann-Whitney U, Kruskal-Wallis testleri kullanılmıştır. İstatistiksel anlamlılık için p<0.05 kabul edilmiştir.

Bulgular: Katılımcıların %44.3'ü erkek ve %55.3'ü evliydi. Çalışmaya katılanların yaş ortalaması 35.00'dı. Katılımcıların çoğu aşı hakkında sağlık personelinden bilgi aldıklarını söyledi. Aşı olanlardan 203'ü aşının kendilerini hastalıklardan koruduğunu düşündükleri için aşı takvimine dahil edildi. 68'i ise aile büyüklerinin etkisi nedeniyle aşı olmadı. Kadınların aşı tereddüdü ölçeği puanı ve 1. alt ölçek puanı erkeklerden anlamlı olarak yüksekti. Eğitim durumu ve ekonomik durum arttıkça aşı tereddüdü ölçeği puanı ve tüm alt ölçek puanları anlamlı olarak azaldı.

Sonuç: Bu çalışma sonucunda Türkiye'de yaşayan göçmenler arasında yaş, çocuk sayısı, Türkiye'de kalış süresi açısından Aşı Tereddüdü Ölçeği ve Alt Ölçek Puanları pozitif korelasyonlar gösterdi. Aşı karşıtlığının temel nedeninin güvensizlik olduğu sonucuna varıldı.

Immigrant vaccination is an important public health measure. Vaccination of immigrants plays a critical role in preventing the spread of diseases and in protecting the most vulnerable people from infectious disease in the host countries. Immigrants due to economic distress, poor health conditions, lack of health services and vaccination programs, are generally more affected by vaccine-preventable diseases ². The fact that Syria is among the few countries where polio is still prevalent and the movement of immigrants to our country represents a risk. Likewise, measles, a preventable pediatric disease, poses a risk for our unvaccinated children. The World Health Organization (WHO) reported that measles, and tuberculosis have been identified in Syrians immigrants in camps in Turkey ³. The Extended Program on Immunization (EPI) initiated by WHO for childhood vaccine-preventable diseases has also been implemented in Turkey and has been made effective with campaigns ⁴. The aim of EPI is to ensure that every baby is vaccinated in accordance with the determined vaccination schedule and that unvaccinated and incompletely vaccinated babies and children are identified and vaccinated ⁵. In our country, pertussis, polio, DTaP, Haemophilus influenzae type b, Hepatitis A, Hepatitis B, mumps, measles, rubella, conjugated pneumococcus, chickenpox, tetanus, tuberculosis vaccines are administered free of charge in health institutions within the scope of EPI ⁴. After the war in Syria, the diphtheria pertussis tetanus vaccination rate dropped from 95% and the measles vaccination rate from 80% to around 50%. 67% of polio cases and 39% of measles cases were seen in war-torn countries, including Syria ⁶. In Syria, due to the unrest and migration that began in 2011, the deterioration of the health system and the decrease in vaccination rates led to the detection of 35 poliomyelitis cases in 2013. It has been determined that the most common reason Syrian parents in Turkey do not vaccinate their children is the language barrier. The reasons for not vaccinating include not having ID records, lack of transportation opportunities, and not knowing where to apply ⁵.

Vaccine hesitancy is based on four interrelated topics: vaccine safety; vaccine efficacy; risk perception; and distrust of governments and health and scientific institutions ^7-10. Anti-vaccination movement has been declared as one of the ten biggest global health threats of 2019 by WHO ¹¹. Two of the most used arguments are the risk and danger related to mercury content in common vaccines, and the ongoing discussion related link between the measles, mumps, and rubella (MMR) vaccine and autism ¹².

Demographic and other factors correlated with vaccine hesitancy comprise residing in a rural area, female gender, lower income, low education level, and vaccine costs ^10,13,14. Several studies worldwide have documented that older individuals, females, those with higher education levels and higher incomes were more likely to accept a vaccine ¹⁵.

It is important to determine the factors that are effective in the emergence of vaccine hesitancy, since there are a serious risk in inadequate vaccination for citizen in countries accepting immigrants. The study aims to determine vaccine hesitancy of Syrian migrants’ and related individual and social factors.

Sample Size: The population of this study consists of Syrian immigrants living in the province of Elazığ. As of 02.06.2022, 13,234 Syrian immigrants live in the province of Elazığ under temporary protection. With the Epi Info program, the minimum sample size was calculated as 250 with a 95% confidence interval and a 5% margin of error, and 273 individuals were reached in this study ^16,17. Participants were reached by going to the regions where Syrians live. Participants were informed that the information received by the researchers before starting the survey would not be used except from the scientific platform of this study.

Inclusion Criteria: Participation in the study was provided on a voluntary basis. Participants were selected from translators who knew Arabic and Turkish, and the questionnaires were filled through face-to-face interview technique.

Exclusion Criteria: Those under the age of 16, those with communication disabilities (hearing and speech impairments) and those who did not were not included in the study.

Developing the Questionnaire: The questionnaire, which was prepared by scanning the literature, was tested by pre-application on 12 immigrants. The questionnaire form consists of socio-demographic information, information about the vaccine and the scale of opposition to the vaccine. The Vaccine Hesitancy Scale (VHS) was developed by Kılınçarslan et al. in 2020 ¹⁸. 5-point Likert scale (1-totally disagree, 5-totally agree) was used for the research and it consists of 12 items and 3 sub-scales. The 1st, 2nd, 3rd, 4th and 5th items of the scale are reversely coded. The score range in the scale varies between 5 and 60, and high scores indicate that the individual's vaccine hesitance attitude level is high. In the study conducted by Kılıçarslan ^19, it was stated that the Cronbach Alpha value of the scale was 0.855. When the reliability of the VHS was examined in the data obtained from the participants in the study, the Cronbach Alpha coefficient of the whole scale was 0.882 and for its sub-scales; Cronbach Alpha coefficient was 0.881 in vaccine benefit and protective value sub-scale (VHS Factor 1), Cronbach Alpha coefficient was 0.807 for anti-vaccine sub-scale (VHS Factor 2), and Cronbach Alpha coefficient was 0.635 for solutions for not being vaccinated sub-scale (VHS Factor 3). Construct validity for the three-scale structure of the VHS was tested with CFA and the statistical values of concordance obtained as a result of the analysis are as follows; (χ2= 160,763; Sd=47; χ2/Sd=3,42; AGFI=0,908; GFI=0,945; CFI=0,955; RMSEA=0,073; RMR=0,055). As a result of the CFA, it was determined that the compliance statistics were acceptable and at a good level. In line with these results, it was concluded that the data obtained from the VHS were valid and reliable. This scale was preferred because it was developed in Turkey and has Turkish validity reliability.

Statistical Analysis: The data obtained as a result of the research were evaluated with the statistical package program. Normality analysis of numerical data was calculated through Kolmogrov Smirnov test. It was determined that the data did not show a normal distribution. The median (minimum-maximum) values of the data were given, and Mann-Whitney U, Kruskal-Wallis tests were used for statistical evaluations. p<0.05 was accepted as statistical significance.

Büyütmek İçin Tıklayın

Table 1: Distribution of participants’ sociodemographic characteristics and Vaccine Hesitance Scale (VHS) scores

Most participants (116) reported receiving information about the vaccine from health staff. Among them, 203 individuals who had been vaccinated were included in the vaccination records, as they believed the vaccine provides protection against diseases. Sixty-eight of them were not vaccinated because of the influence of their family elders. As the reason for not vaccinating, the majority stated that they were afraid that other diseases might arise due to vaccines in the future and they thought that the substances in the vaccine had harmful side effects (Table 2).

Büyütmek İçin Tıklayın

Table 2: Distribution of answers given to some questions

VHS score and 1st sub-scale (VHS Factor 1) score of women were significantly higher than among men. As the educational status and economic status (self-reported) increased, the VHS score and the scores of all sub-scales decreased significantly. VHS scores and Mean Rank values of all sub-scales were significantly higher for those who did not work than for those who worked and than those who did not have knowledge about the vaccine (self-reported). Similarly, the scores are higher for those who did not have the vaccination calendar compared to those who had the vaccine schedule, and those who did not want to receive information about the vaccine compared to those who wanted to know about the vaccine (Table 3).

Büyütmek İçin Tıklayın

Table 3: Variation of Vaccine Hesitance Scale (VHS) and Subgroup Scores (Factor 1, 2, 3) by Socio-demographic Characteristics

Age, number of children, duration of stay in Turkiye (years), VHS and Subscale (Factors 1, 2, 3) Scores showed positive correlations (Table 4).

Büyütmek İçin Tıklayın

Table 4: The Relationship between Age, Number of Children, Time spent in Turkiye, and Vaccine Hesitance Scale (VHS) and Subscale Scores (Factor 1, 2, 3)

Among the study participants, the number of men was higher than other studies, the percentage of women and men was close, and the average age was 35.00. Studies on immigrants in Turkiye have reported that it is difficult to reach the young male population ²². In this study, despite all the limitations, data from the young male immigrant population was obtained. This is one of the strengths of the study. The average VHS score of the participants in the study was 29 (close to half of the highest point 60). In a study conducted in Turkiye using the long form of the same scale, nurses' anti-vaccination scale score was 46.82 (close to half of the highest score 105) ²³. The fact that the VHS of immigrants and local health workers were similar suggested that it could be associated with feeling safe in the country. Many Syrian immigrants stated that they had their children vaccinated according to the vaccination schedule in their own countries. The most common reason for not continuing to vaccinate in Turkey was stated as "language problem". Other reasons were identified as the lack of ID records, transportation difficulties, and not knowing where to apply ⁵. It is anticipated that immigrants in Türkiye will be vaccinated once they have access to vaccines. Considering the reasons why immigrants do not get vaccinated, EPI and other national campaigns on this issue are expected to increase vaccination among immigrants.

As the education and economic status increased, the VHS score and the scores of all sub-scales decreased significantly. Seeing the positive impact of education and accessibility will shed light on strategies to produce solutions in this area. VHS scores and scores of all sub-scales were significantly higher in those who did not have self-reported knowledge about the vaccine, those who did not have the vaccine calendar, and in those who did not want to receive information about the vaccine compared to those who wanted. In the study in which the VHS was used, the vaccine hesitancy score of those who did not know about the vaccine was found to be high ²³. This shows that the lack of information about the vaccine poses a risk in terms of anti-vaccination and this information can be used to prevent vaccine rejection.

Similar to the other studies, the scale scores of those who had children were found to be lower ²³. Among parents, vaccination hesitance were lower because they cared more about their children and researched their vaccinations.

In terms of staying duration in Turkiye, positive correlation of VHS and Subscale Scores were associated with an increase in confidence as they lived in the country.

In a study conducted in a Turkish population, vaccine hesitancy scores were higher among younger individuals, whereas in the present study, the VHS score increased with age ²⁴. In this study, age and VHS score showed a positive correlation. This result shows the difference between the immigrant society and the native society.

In this study, the main reason for vaccine hesitancy was the belief that the substances in vaccines have harmful side effects and the fear that other diseases may arise in the future due to vaccination. Similarly, it has been observed that not trusting the vaccine is among the reasons for vaccine hesitancy ²⁴. In addition, it has been determined that vaccine acceptance in other societies is associated with trust in the host country, and a reliable health care provider is the main factor determining vaccine acceptance and rejection ²⁵. A study conducted in Lebanon found that Syrian immigrants were as compliant with mandatory vaccinations as local people. However, the vaccination rate of immigrants is lower than that of local people in non-compulsory vaccines ²⁶. This can be explained by the fact that mandatory vaccines are free in Lebanon, while non-compulsory vaccines are charged. When vaccines are made available, immigrant compliance appears to increase.

As a result of this study, positive correlations were found between age, number of children, duration of stay in Türkiye, and VHS and subscale scores among immigrants living in Turkiye. It has been concluded that the main reason for vaccine hesitancy is insecurity. In addition, because VHS scores were higher among women, it is recommended that women, particularly those who are undereducated, elderly, and have children, should be considered priority groups for vaccination education for the health of immigrants and the wider community. Also campaigns should be carried out to increase access to vaccination among immigrants, and free and on-site services (where immigrants live) should be provided.

1) Binici N, Börekçi G. Determination of vaccination status of children coming from Syria with immigration. ESTUDAM Public Health Journal 2021; 6(2): 169-181.

2) Ravensbergen SJ, Nellums LB, Hargreaves S, Stienstra Y, Friedland JS. Working Group on Vaccination in Migrants. National approaches to the vaccination of recently arrived migrants in Europe: A comparative policy analysis across 32 European countries. Travel Med Infect Dis 2019; 27: 33-38.

3) Ekmekci PE. Syrian refugees, health and migration legislation in Turkey. J Immigr Minor Health 2017 ; 19(6): 1434-1441.

4) Gülcü S, Arslan S. Vaccine application on children: A Current Review. Value in Health Sciences 2018; 8(1): 34-43.

5) Shahid ASMSB, Rahman AE, Shahunja KM, et al. Vaccination following the expanded programme on immunization schedule could help to reduce deaths in children under five hospitalized for pneumonia and severe pneumonia in a developing country. Front Pediatr 2023; 11: 1054335.

6) Grundy J, Biggs BA. The impact of conflict on immunisation coverage in 16 countries. Int J Health Policy Manag 2019; 8: 211-221.

7) Loomba S, de Figueiredo A, Piatek SJ, de Graaf K, Larson HJ. Measuring the impact of COVID-19 vaccine misinformation on vaccination intent in the UK and USA. Nat Hum Behav 2021; 5: 337-348.

8) Aw J, Seng J, Seah S, Lo L. COVID-19 vaccine hesitancy—a scoping review of literature in high-income Countries. Vaccines 2021; 9: 900.

9) Al Shurman BA, Khan AF, Mac C, Majeed M, Butt Z A. What demographic, social, and contextual factors influence the intention to use COVID-19 vaccines: A scoping review. Int J Environ Res Public Health 2021; 18: 9342.

10) Lazarus JV, Wyka K, White TM, et al. Revisiting COVID-19 vaccine hesitancy around the world using data from 23 countries in 2021. Nat Commun 2022; 13: 3801.

11) World Health Organization. “Ten threats to global health in 2019”.https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019 / 19.03.2024.

12) Naprawa AZ. Don’t give your kid that shot: The public health threat posed by anti-vaccine speech and why such speech is not guaranteed full protection under the first amendment. Cardozo Public Law Policy Ethics J 2012; 11.

13) Bono SA, Faria de Moura Villela E, Siau CS, et al. Factors affecting COVID-19 vaccine acceptance: An international survey among Low- and Middle-Income Countries. Vaccines (Basel) 2021; 9(5): 515.

14) de Figueiredo A, Larson HJ. Exploratory study of the global intent to accept COVID-19 vaccinations. Communications Medicine 2021; 1(1): 1-10.

15) Soares P, Rocha JV, Moniz M, et al. Factors associated with COVID-19 vaccine hesitancy. Vaccines 2021; 9(3): 300.

16) Kurçer MA, Şimşek Z, Solmaz A, Dedeoğlu Y. Vaccination rate and problems of 0-2 aged children and pregnant women in Harrankapı Health Center Region. Journal of Harran University Medical Faculty 2005; 2(2): 10-15.

17) Gülgün M, Fidancı K, Karaoğlu A, et al. Investigation of 0-24 months vaccination status in children applied to pediatric outpatient clinic in a military hospital. Gülhane Med J 2014; 56: 13-16.

18) Kılınçarslan MG, Sarıgül B, Toraman Ç, Şahin EM. Development of valid and reliable scale of vaccine hesitancy in Turkish language. Konuralp Medical Journal 2020; 12(3): 420-429.

19) Kılınçarslan MG, Coşkuntuncel C, Şahin EM. Determination of cut-off value of the turkish vaccine hesitation scale for healthcare workers. Turkish Journal of Family Medicine and Primary Care. 2023; 17(2): 271-275.

20) Dukes K, Johnson C, Sinnwell E, et al. Vaccination is important to protect migrant communities but should be part of a multifaceted approach. Workplace Health Saf 2022; 70(7): 309.

21) Mazzitelli M, Greco G, Serapide F, et al. Outcome of HBV screening and vaccination in a migrant population in southern Italy. Infez Med 2021; 29(2): 236-241.

22) Karadag O, Kilic C, Kaya E. et al: Challenges and lessons learned in mental health research among refugees: A community-based study in Turkey. BMC Public Health. 2021;21, 1537.

23) Güneş H, Semerci V, Kırbaş ZÖ: Determination of nurses' anti-vaccination levels. Mersin Unv Journal of Health Sciences 2023; 16(1): 93-102.

24) Bayır B, Yağız FN, Çat R, Çat G. Determining The attitudes of individuals in the community towards vaccine applications and their attitudes after the Covid-19 pandemic. Journal of Adnan Menderes University Health Science Faculty 2023; 7(1): 38-48.

25) Nichol AA, Parcharidi Z, Al-Delaimy WK, Kondilis E. Rapid review of COVID-19 vaccination access and acceptance for global refugee, asylum seeker and undocumented migrant populations. Int J Public Health. 2022; 22(67): 1605508.

26) Kmeid M, Azouri H, Aaraj R, Bechara E, Antonios D. Vaccine coverage for Lebanese citizens and Syrian refugees in Lebanon. Int Health. 2019 Nov 13; 11(6): 568-579.