RESEARCH ARTICLEOpen Access
Healthcare workers as parents: attitudes toward
vaccinating their children against pandemic
Sebahat D Torun1*, Fuat Torun2, Binali Catak3
Background: Both the health care workers (HCWs) and children are target groups for pandemic influenza
vaccination. The coverage of the target populations is an important determinant for impact of mass vaccination.
The objective of this study is to determine the attitudes of HCWs as parents, toward vaccinating their children with
pandemic influenza A/H1N1 vaccine.
Methods: A cross-sectional questionnaire survey was conducted with health care workers (HCWs) in a public
hospital during December 2009 in Istanbul. All persons employed in the hospital with or without a health-care
occupation are accepted as HCW. The HCWs who are parents of children 6 months to 18 years of age were
included in the study. Pearson’s chi-square test and logistic regression analysis was applied for the statistical
Results: A total of 389 HCWs who were parents of children aged 6 months-18 years participated study. Among all
participants 27.0% (n = 105) reported that themselves had been vaccinated against pandemic influenza A/H1N1.
Two third (66.1%) of the parents answered that they will not vaccinate their children, 21.1% already vaccinated and
12.9% were still undecided. Concern about side effect was most reported reason among who had been not
vaccinated their children and among undecided parents. The second reason for refusing the pandemic vaccine
was concerns efficacy of the vaccine. Media was the only source of information about pandemic influenza in
nearly one third of HCWs. Agreement with vaccine safety, self receipt of pandemic influenza A/H1N1 vaccine, and
trust in Ministry of Health were found to be associated with the positive attitude toward vaccinating their children
against pandemic influenza A/H1N1.
Conclusions: Persuading parents to accept a new vaccine seems not be easy even if they are HCWs. In order to
overcome the barriers among HCWs related to pandemic vaccines, determination of their misinformation, attitudes
and behaviors regarding the pandemic influenza vaccination is necessary. Efforts for orienting the HCWs to use
evidence based scientific sources, rather than the media for information should be considered by the authorities.
Pandemic influenza A/H1N1 virus causes disease in all
age groups, but it affects children stronger than adults
in terms of attack rate and disease severity [1-3].
A study from United States reports that children were
twice as susceptible to infection with the 2009 H1N1
virus from a household member as adults 19 to 50 years
of age . Nearly 30% of the first reported cases of
pandemic influenza A/H1N1 in Turkey have involved
persons who were 18 years of age or younger .
The social contact network, and the way people inter-
act within, is critical to the spread of influenza .
Children are under greater risk for influenza infection
because they experience a large number of extra-house-
hold contacts with their peers in daycare centers or
schools and some of the most intense outbreaks have
been associated with schools [7-9].
Healthcare workers have increased risk of getting
infected with influenza during outbreaks because they
are exposed to infected individuals in the community as
* Correspondence: firstname.lastname@example.org
1Assistt Rehberlik ve Müsteri Hizmetleri A.S., Istanbul, Turkey
Full list of author information is available at the end of the article
Torun et al. BMC Public Health 2010, 10:596
© 2010 Torun et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
well as hospitalized patients with influenza. They may
become an important reservoir of influenza virus for
vulnerable patients under their care [10-12] and espe-
cially for the children in their household . Being a
child of a HCW parent theoretically will increase the
risk of influenza infection of the child, although no
quantitative information is available on the subject. On
the other hand it is reported that family members with
influenza, especially children, rather than the daily bur-
den of influenza patients, make every General Practi-
tioner, vaccinated or not, very vulnerable to infectious
influenza . The role of children as the main sources
of influenza transmission within a community or house-
hold has been referred in many studies [15-17].
The most effective countermeasure against a pan-
demic virus will be a specific pandemic vaccine available
for the whole population . However the supply of
vaccines will be limited at least during the beginning of
the influenza pandemic. Therefore, prioritization in the
administration of the limited vaccine supply has been
one of the major components in pandemic prepared-
ness. The World Health Organization (WHO) recom-
mends that HCWs, children aged above 6 months with
one of several chronic medical conditions and healthy
children should be considered as priority groups for
pandemic influenza [19,20].
But influenza vaccine acceptance by HCWs is low
even in the setting of pandemics [21-24].
Following the recommendations of the WHO, Turkish
public health authorities have decided to start a mass
vaccination campaign to mitigate the transmission of
the pandemic influenza A/H1N1. The MoH has pur-
chased 8 million doses of pandemic vaccine. In the first
phase of vaccination campaign, vaccination has been
offered to health care providers, people between the
ages of 6 months and 50 years with underlying condi-
tions, healthy people between 6 months and 24 years of
age, pregnant women and Haj pilgrims . On Novem-
ber 2, 2009, the vaccination campaign started in the
country and vaccination was free of charge . Pan-
demic influenza vaccination was not mandatory. Mass
vaccination of schoolchildren in schools has been
planned to begin at December. Until that date parents
could vaccinate their children in primary health care
settings. Vaccination of children in schools depended on
written parental consent. Because the ratio of parents
who gave written consent for vaccination of their chil-
dren in schools was very low all over the country, the
MoH cancelled the mass vaccination in schools and
schoolchildren continued to be vaccinated in primary
health care settings .
The aim of this study was to examine the attitudes of
hospital HCWs as parents of children aged 6 months to
18 years compliance with pandemic influenza A/H1N1
vaccine during pandemic alert phase 6 in Istanbul.
Study design and participants
This study was conducted at Umraniye Research and
Training Hospital (URTH), Istanbul, Turkey from 7-22
December 2009. The study hospital, hospital workforce
and the population of the study have been reported else-
where . The participants of the previous reported
study made up the study population of this study.
Among all the 718 participants of the reported study,
389 HCWs met the inclusion criteria of being a parent
of a child 6 month to 18 years of age.
Data was collected by a self- administered, anonymous
questionnaire [Additional File 1] which the participants
could complete in less than ten minutes. During the
time when the previous study questionnaires were taken
up, the questionnaire was delivered by hand directly to
the participants and taken back by the second author
who is one of the HCWs at the study hospital. The
questionnaire consisted of questions regarding age, sex,
marital status, occupation, years of work in health
services, history of seasonal influenza vaccination in
2009, source of knowledge for pandemic influenza, per-
ception of risk and seriousness of pandemic influenza,
agreement with pandemic vaccine safety and efficacy,
confidence to Ministry of Health (MoH) about pan-
demics, children 6 months to 5 years of age in the
household, school children (6 to 18 years of age) in the
household, whether respondents and their children are
vaccinated with pandemic influenza H1N1 vaccine and
if not reasons for refusing pandemic influenza vaccine.
Occupation was stratified into four groups based
primarily upon education and training: (1) doctor, (2)
nurse, (3) professional support staff and (4) nonprofes-
sional support staff.
A brief oral and written description of the aim of the
study was given to all the participants and verbal con-
sent was obtained from the participants. Completed
questionnaires were collected from the participants by
the researchers within following days.
At time of our study was planned the activities of all the
Research Ethic Committees (REC) were stopped in Turkey
because the Turkish Medical Association has filed an
action on 23 February 2009 requesting the cancellation of
some of the provisions of the Regulation on the grounds
that they are not in conformity with the international
agreements in which Turkey is bound by . Judicial
order of the Council of State on 13.11.1009 with issue
2009/3991 E was motion for stay . Authorization of
Torun et al. BMC Public Health 2010, 10:596
Page 2 of 6
our study is taken from Istanbul Provincial Directorate of
Data was analyzed by SPSS 10.0 version. Descriptive sta-
tistics were computed for the survey responses and
demographic information. The main outcome variable
was the parental attitude towards vaccinating their chil-
dren against pandemic influenza A/H1N1 (vaccinated
versus not vaccinated). By cross tabulations, we analyzed
univariate associations between attitude towards vacci-
nating their children against pandemic influenza
A/H1N1 and the following variables: sex, age, occupa-
tion, duration of employment in health care service,
self-vaccination against pandemic influenza A/H1N1and
receiving seasonal influenza vaccine in 2009, source of
knowledge about pandemic influenza, how serious they
thought is the pandemic, weather they trust to the infor-
mation they receive from Ministry of Health (MoH),
agreement with pandemic vaccine safety and efficacy
and agreement with some other statements related to
pandemic. Pearson’s Chi-square test was used for statis-
Univariate associations between child’s pandemic
influenza A/H1N1 vaccination status and other variables
were tested by logistic regression. All independent fac-
tors associated with the acceptance of pandemic influ-
enza A/H1N1 vaccination in cross tabulations were
subsequently introduced in a backward multivariate
logistic model. All of the analyses were two tailed, and
p values < 0.05 considered as significant.
Self- reported pandemic influenza A/H1N1 vaccine
receipt was not statistically different (p > 0.05) in HCWs
who were parents of children 6 months-18 years and the
other interviewed HCWs (24.4% and 20.6% respectively).
Because the particular purpose of this report was to eval-
uate the attitudes of HCWs towards vaccinating their
children with pandemic influenza A/H1N1 vaccine, data
of 389 HCWs who have children aged 6 months-18
years, was further analyzed. Among 389 of HCWs 57.3%
were female; their mean age was 35.0 ± 7.0 years (range
20-56 years); median time of occupation in health care
service 96.0 months (range 1- 420 months). Seventy
seven percent of parents had children who were 6 month
to 18 years of age, while 22.9% had children only children
6 month to 5 years of age. Doctors and nurses made up
50.1% (n = 195) of the respondents. Table 1 represents
the characteristics of the participants and results of uni-
variate analyzes. One-hundred and five (27.0%) of the
participants reported that themselves have been vacci-
nated against pandemic influenza A/H1N1. Among all
parents 22.1% (n = 82) already get vaccinated their
children against pandemic influenza A/H1N1, 66.1% (n =
257) do not plan to get their children vaccinated and
12.9% (n = 50) were still undecided. Among parents who
do not plan to get their children vaccinated against pan-
demic influenza A/H1N1 or who were undecided about
vaccination, the main reasons given for refusal were con-
cerns about vaccine safety (245/307, 79.8%), or the
respondents did not believe in efficacy of vaccination
(177/307, 57.7%). Twenty one (6.84%) parent reported
their reason for refusing the vaccine as “just don’t want
to get vaccinate”. Other reasons given for refusal of vacci-
nation included because the child has had the seasonal
influenza vaccination (22/307, 7.2%), “just don’t want to
get vaccinate the child” (21/307, 6.8%), and because the
prime minister did not get the vaccine (4/307).
The most reported source of information about pan-
demic influenza was media (television and newspaper)
(83.0%). Nearly one third of the participants (31.4%)
reported the media (television and newspapers) as their
only source of information about pandemic influenza
A/H1N1. The other most reported sources were Turkish
Ministry of Health (49.6%), colleagues/doctors (49.4%),
World Health Organization (13.6%), educational semi-
nars of local health authority of the city (11.1%) and
Centers for Disease Control and Prevention (3.1%).
An important proportion (42.4%) of the parents
reported that did not trust in the declarations and sug-
gestions of Turkish Ministry of Health (MoH) about
pandemic influenza. No association was found between
trust in the MoH and occupation.
Univariate analysis showed that gender, occupation,
parents’ self vaccination against pandemic influenza,
source of knowledge regarding pandemic influenza,
agreement with pandemic vaccine safety, agreement
with vaccine efficacy and trust in the declarations and
suggestions of MoH were significantly associated with
the parental attitude toward vaccinating their children
against pandemic influenza A/H1N1 (Table 1).
Logistic regression analysis showed that agreement/
strong agreement with safety of the pandemic influenza
vaccine (OR = 2.351; 95%CI: 1.116 - 4.953) and self
receipt of pandemic influenza vaccine (OR = 13.624;
95%CI: 7.140 - 25.993) were significantly associated with
positive parental attitude to vaccinate their children
with pandemic influenza vaccine (Table 2).
Our study revealed a low (21.1%) pandemic influenza
A/H1N1 vaccination rate among children whose parents
are healthcare workers. A study conducted in Italy at
WHO pandemic alert phase 6 reports that 12.8% of
mothers would have their children vaccinated, whereas
44.4% would remain doubtful . Although in our
study, the vaccination rate among children whose
Torun et al. BMC Public Health 2010, 10:596
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Table 1 Characteristics of the respondents by attitude towards vaccinating their children (Values are percentages of
Attitude towards vaccinating their children
Characteristic of parentsTotal
(N = 389)
(N = 82)
(N = 257)
(N = 50)
Female57.3 17.5 71.710.8 0.023
Doctor 27.532.7 55.1 12.10.004
Professional support staff11.8 15.260.9 23.9
Nonprofessional support staff38.0 16.973.69.5
Years of work in health services
< 5 40.119.9 69.910.3 0.361
5-9 12.6 22.4 71.4 6.1
≥ 1531.6 22.0 60.2 17.9
Received pandemic influenza vaccine
Yes 27.060.0 24.8 15.2< 0.000
No73.06.7 81.3 12.0
Sources of information*
WHO and/or CDC besides MoH13.637.752.89.4 0.003
MoH 36.022.2 62.115.7
Physicians (no any health authority)19.023.0 62.214.8
Only media (television/newspaper)31.411.578.79.8
Pandemic influenza A/H1N1 vaccine is safe
Agree/strong agree 48.636.046.6 17.4< 0.000
Disagree55.6 7.084.5 8.5
Vaccine is effective in preventing pandemic influenza
Agree/strong agree56.331.5 52.116.4 < 0.000
Disagree 43.77.784.1 8.2
Trust the declarations and suggestions of Ministry of Health
Yes57.6 29.556.2 14.3 < 0.000
*MoH: Ministry of Health, WHO: World Health Organization, CDC: Centers for Disease Control and Prevention.
Table 2 Logistic Regression Analysis: Factors associated with vaccinating their children with pandemic influenza
FactorsOdds Ratio95% CIp value
Self receipt of pandemic influenza vaccine
Yes13.6247.140 - 25.993 0.025
Agreement with pandemic influenza A/H1N1 vaccine safety
Agree/strong agree2.351 1.116 - 4.953 0.000
Trust in the declarations and suggestions of Ministry of Health
Torun et al. BMC Public Health 2010, 10:596
Page 4 of 6
parents were doctor was higher (32.7%) than the chil-
dren whose parents were nurse or support staff, we can
come to the conclusion that even doctors, who are the
most educated HCWs, were resistant to vaccinating
their children against pandemic influenza A/H1N1. A
recent study reports high education of the parent, being
a health care worker and perception of vaccine ineffec-
tiveness as determinants of fully negative attitude
towards vaccination .
Lack of confidence in the MoH among our study popu-
lation was thought provoking. The no confidence prob-
ably can be explained with dissidence between the MoH
as the main authority in the national pandemic plan and
the Turkish prime minister (the prime minister of the
country had declared on November that neither he nor
any one from his family will get the pandemic vaccine).
This situation had found an important place the national
media . Unjustified fears about the adverse effects of
pandemic influenza A/H1N1 vaccine, among HCWs as
well as the public, have certainly been influenced by the
mixed messages coming from vaccine-resistant Prime
Minister. Media seems to be an important source of
information (and sometimes the only information source
even among doctors and nurses) about pandemic influ-
enza A/H1N1 in our study population. Media can be
accepted as a primary source of information in the gen-
eral public, but our study group was HCWs and half of
them were doctors and nurses. We believe that this find-
ing is needs special investigation because in our opinion
evidence based scientific sources and health authorities
instead of the media should the primary information
source of health care professions.
HCWs play a critical role in disseminating accurate
information about pandemic influenza A/H1N1 vaccine.
Besides being the main persons for implementation of
pandemic influenza A/H1N1 vaccine, the HCWs and their
family members are recipients of the vaccine. Therefore
believes and attitudes of HCWs towards pandemic influ-
enza A/H1N1 vaccination, can play an important role in
supporting or blocking the vaccination efforts. A negative
attitude of a HCW towards vaccination may grow as a
snowball. A negative attitude of a HCW as a parent of a
school child or a day care child, towards pandemic influ-
enza vaccination possibly may have negative impact on the
decision of the other parents of the classmates and tea-
chers. An online survey conducted by a research company
in Turkey, reports that out of 8,600 respondents 95% had
not been vaccinated against pandemic influenza A/H1N1.
Eleven percent of negative respondents had consulted a
doctor about the vaccine, and therefore argues in the
negative opinions and 10% percent said they were influ-
enced by unfavorable opinion of Prime Minister, who pre-
viously said he would not receive the vaccine, in choosing
refusing of the vaccine .
Our study has some limitations, and the results should
be interpreted with these limitations. First limitation is
that it covers only one hospital. Another limitation is
the lack of details (especially their parental status) for
the HCWs that we could not been interviewed (223/
941, 23.6%) mainly because of the shift work in the hos-
pital. Therefore a selection bias could have occurred.
Lack of details about the age of their children and the
fact that children could have chronic underlying disease
is another important limitation of our study. Self-report-
ing vaccine uptake of children might be a potential bias
also. All these points might limit to generalize our study
results. Nevertheless, our study gives important informa-
tion about HCWs actual attitudes as parents towards
vaccinating their children with pandemic influenza A/
H1N1 vaccine because it was conducted at an advance
of pandemic phase.
Despite some limitations, our survey could be a useful
tool for decision makers to promote programs and cam-
paigns aimed at informing and educating HCW as well
This study supports that persuading parents to accept a
new vaccine seems not be easy even if they are HCWs.
In order to overcome the barriers for vaccination among
HCWs, determination of their misinformation, attitudes
and behaviors regarding the pandemic influenza vacci-
nation seems to be essential. For effectiveness of mass
vaccination campaigns coherence between the authori-
ties is important. Efforts for orienting the HCWs (espe-
cially doctors and nurses) to use medical and evidence
based scientific sources, rather than the media for infor-
mation related to health should be considered by the
authorities. Efforts should be made to inform HCWs
regarding the benefits of vaccination and the potential
health consequences of influenza illness for their
patients, themselves, and their family members.
Educational campaigns concerning the HCWs should
include evidence based and comprehensible information
about possible adverse effects of the vaccine and their
Additional file 1: Questionnaire. The questionnaire which was the
source of information utilized in this article is shown, translated from
1Assistt Rehberlik ve Müsteri Hizmetleri A.S., Istanbul, Turkey.2Umraniye
Research and Training Hospital, Istanbul, Turkey.3Karabük Public Health
Torun et al. BMC Public Health 2010, 10:596
Page 5 of 6
SDT designed the study, reviewed the literature, analyzed the data and was
responsible for writing the manuscript. FT participated in the coordination of
the study, collected and entered the data, helped to literature review. BC
helped to draft the manuscript and to interpret the results. All of the
authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Received: 2 March 2010 Accepted: 10 October 2010
Published: 10 October 2010
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The pre-publication history for this paper can be accessed here:
Cite this article as: Torun et al.: Healthcare workers as parents: attitudes
toward vaccinating their children against pandemic influenza A/H1N1.
BMC Public Health 2010 10:596.
Torun et al. BMC Public Health 2010, 10:596
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