40 | pISSN: 1858-3598  eISSN: 2502-5791 Jurnal Ners Vol. 15, No. 2, Special Issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18907 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License Original Research Factors Related to Vaccine Hesitancy in Anti-vaccine Group on Facebook Aisyah Nur Izzati, Budi Utomo, Retno Indarwati Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia ABSTRACT Introduction: The current controversial issue regarding the anti-vaccine movement is the biggest challenge in implementing immunization in Indonesia because it influences the stagnation in the coverage of complete basic immunization. The World Health Organization (WHO) also states that the anti-vaccine group is one of the ten major threats to global health in 2019 since this phenomenon can cause rare diseases to become epidemic. This study aims at factors related to vaccine hesitancy in the anti-vaccine group on Facebook. Methods: This study used a descriptive correlational method with a quantitative approach. The sample in this study was 150 mothers who were members of the anti-vaccine group on Facebook social media, selected using a purposive sampling technique. Results: Demographic characteristics include religion, ethnicity, education, and income. Perceived susceptibility and perceived severity were assessed using Hwang’s Health Belief Model questionnaire, while vaccine hesitancy was assessed using Saphiro’s Vaccine Hesitancy Scale questionnaire, then analyzed using Spearman Rho (α<0.05). The results of this study showed that there was a correlation between perceived susceptibility and perceived severity of vaccine hesitancy (p=0.000), while demographic characteristics were not related to vaccine hesitancy. Conclusion: Certain religions and ethnicities which have caused concern have proven unrelated to parent’s hesitance in immunization, as well as the level of education and income. The vulnerability and severity of a disease emerged as most parents’ overriding concern when making decisions about vaccine ARTICLE HISTORY Received: Feb 27, 2020 Accepted: April 1, 2020 KEYWORDS perceived susceptibility; perceived severity; vaccine hesitancy; anti- vaccine CONTACT Retno Indarwati  retno-i@fkp.unair.ac.id  Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia Cite this as: Izzati, A, N., Utomo, B., & Indarwati, R. (2020). Factors Related to Vaccine Hesitancy in Anti-vaccine Group on Facebook. Jurnal Ners, Special Issues, 40-44. doi: http://dx.doi.org/10.20473/jn.v15i2.18907 INTRODUCTION The controversial problem regarding vaccines, especially the recent vaccine hesitancy, is the biggest challenge in implementing immunization in Indonesia (Depkes RI, 2018). According to the Strategic Advisory Group of Experts (SAGE) Vaccine Hesitancy working group of WHO, vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite the availability of vaccine services. This certainly affects the stagnation of complete basic immunization coverage in Indonesia. Meanwhile, to be able to provide effective protection, immunization coverage must be maintained high and evenly distributed throughout the regions to avoid extraordinary events (KLB) (Depkes RI, 2018). The World Health Organization ( 2018) also stated that the anti-vaccine group is one of the ten major threats to global health in 2019 because this phenomenon can cause rare diseases to become epidemic again (WHO, 2018). The achievement of complete basic immunization must pass various challenges, one of which is the public’s trust in the immunization program. Schalkwyk (2019)explained that most of the anti- vaccine group movement use social media to spread misleading information about vaccines to strengthen the hesitancy of others in giving vaccines to their children (Schalkwyk, 2019). Social media is chosen because it is the only media currently used by everyone to interact, search for information, and to become part of a community (Joubert, 2019). The https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:retno-i@fkp.unair.ac.id JURNAL NERS http://e-journal.unair.ac.id/JNERS | 41 most widely used type of social media to spread anti- vaccine propaganda is the Facebook Group (Chiou & Tucker, 2018). Indonesia is the fourth highest user of Facebook social media in the world with 130 million active users per month (Hootsuite and We Are Social, 2018). The results of the study by the Ipsos-Centre for International Governance Innovation (CIGI) showed that 65%of internet and social media users in Indonesia believe in the truth of the information in cyberspace without making confirmation beforehand. Various arguments about the pros and cons of vaccination that are widely communicated on social media make ordinary people directly accept the information and are more influenced by counter statements about vaccination (Sundoro et al., 2018). Trust and legitimacy are crucial concepts for understanding why some sources of information on vaccination can lead to vaccine hesitancy because the fear of disease, which we term perception of susceptibility and severity, has been replaced by fear of vaccines for some people... The phenomenon that is happening in the midst of the community surely becomes a concern of all health workers in the world, including in Indonesia. A number of studies on cons of vaccination have been examined in several other countries, but there are still very few studies in Indonesia. The background underlies this study’s intent to analyze the hesitancy of basic immunization in the anti-vaccine groups on Facebook social media. MATERIALS AND METHODS The data of this study have been collected by distributing questionnaires through Google Form to 150 mothers who joined the anti-vaccine Facebook Group and were selected with a purposive sampling technique. A section of the questionnaire consists of religion, race disparities, level of education, level of income, perceived susceptibility, and perceived severity. A scale from one to four has been used in the questionnaires to determine the level of vaccine hesitancy. The questionnaires were distributed on the first of December 2019 and collected on the fifth of February 2020. After the questionnaires were collected, experts’ answers were extracted using coding method and transferred to an Excel spreadsheet. The data were transferred to the coding Excel spreadsheet and grouped to summarize similar opinions in tables to present the percentages. This study has received ethical approval from The Research Ethic Committee, Faculty of Nursing Universitas Airlangga with Letter of Approval No: 1837-KEPK. RESULTS The first section of this study explains basic information regarding age, area of residence, occupation, religion, ethnicity, education level, and income level of the respondents. The data show that 34% of the respondents are in the age range of 26-30 years, 31% of them are in the age range of 31-35 years, 21% of them are in the age range of 36-40 years, and the rest are under 25 years old. A Of the respondents, 53.3% live in urban areas and the remaining 46.7% live in villages. Housewives account for 56% of the respondents , 24% of them are self- employed, 14% of them are civil servants, and the remaining 9% work as merchants. Almost all of them are predominantly Muslim with a percentage of 97.3%, 2% are Christians, and the remaining 0.7% are Catholics. The ethnicity of the respondents are quite diverse, but the majority or 88.7% of the respondents Table 1. Percentage distribution of demographic characteristics of the respondents Demographic Characteristics Category n % Age 18-25 years old 21 14 26-30 years old 51 34 31-35 years old 47 31.3 36-40 years old 31 20.7 Religion Islam 146 97.3 Christian 3 2 Catholic 1 0.7 Ethnicity Java 133 88.7 Madura 4 2,7 Batak 6 4 Chinese 3 2 Osing 2 1.3 Bali 2 1.3 Area of residence Urban 80 53.3 Rural 70 46.7 Level of education Primary school 2 1.3 Junior high school 3 2 Senior high school 53 35.4 College 92 61.3 Occupation Housewife 84 56 Wiraswasta 36 24 PNS 21 14 Pedagang 9 6 Level of income <2.500.000 70 46.7 >2.500.000 80 53.3 A. N. IZZATI ET AL. 42 | pISSN: 1858-3598  eISSN: 2502-5791 are Javanese, 4% are Bataknese, 2.7% are Madurese, 2% are Chinese, and the remaining 2.6% are Osing and Balinese. Only 1.3% graduated from elementary schools, 2% graduated from junior high schools, 35.4% graduated from senior high schools, and the remaining 61.3% graduated from universities. Having an income of above IDR 2,500,000 accounted for 53.3% of the respondents and the remaining 46.7% have an income of below IDR 2,500,000 (Table 1). Table 3 shows the results of bivariate analysis between the dependent variables and the independent variables, where if a p-value is less than 0.05 . it is statistically significant. There was no significant relationship between religion and vaccine hesitancy (p=0.148 r=-0.119), there was no significant relationship between ethnicity and vaccine hesitancy (p=0.127 r=0.125), between level of education and vaccine hesitancy (p=0.560 r=- 0.097), or between level of income and vaccine hesitancy (p=0.560 r=-0.048), but there was a significant relationship between perceived susceptibility and vaccine hesitancy (p=0.000 r=0.323), and between perceived severity and vaccine hesitancy (p=0.000 r=0.292). DISCUSSION The results of this study indicate that demographic characteristics do not affect immunization hesitancy in parents. A study conducted by Calu in 15 countries showed lower immunization coverage among Muslims than Christians (Calu et al., 2020) This phenomenon of vaccine refusal has also been recently reported in developed countries, such as in the United States with religious concerns being a major reason (Review, 2016). However, a study carried out by Larson in 2016 explained that studies on vaccine confidence showed that Muslim faith itself is not always linked to low coverage, for example in Saudi Arabia (Larson et al., 2016). This study revealed that religion is not related to vaccine hesitancy in the anti- vaccine group on Facebook in Indonesia. This is consistent with a study conducted by Pelčić in 2016 which found that every religion has its own basic reasons for not giving immunizations to the children Table 2. Percentage distribution of the perceived susceptibility and severity of the respondents Perceived Susceptibility Strongly Agree Agree Disagree Strongly Disagree Total My child is at risk for PD3I ((Infectious disease that can be prevented by immunization) or vaccine-preventable diseases (tuberculosis, polio, hepatitis B, pertussis, diphtheria, measles and tetanus) 7 47 59 37 150 I am worried that my child will have PD3I or vaccine- preventable diseases (tuberculosis, polio, hepatitis B, pertussis, diphtheria, measles, and tetanus) 29 65 43 13 150 PD3I or vaccine-preventable diseases (tuberculosis, polio, hepatitis B, pertussis, diphtheria, measles and tetanus) are contagious diseases 41 82 19 8 150 PD3I or vaccine-preventable diseases (tuberculosis, polio, hepatitis B, pertussis, diphtheria, measles and tetanus) are dangerous for my child 63 73 11 3 150 PD3I or vaccine-preventable diseases (tuberculosis, polio, hepatitis B, pertussis, diphtheria, measles and tetanus) can cause serious health problems for my child 58 75 15 2 150 The provision of immunizations is important for maintaining the health of my child 23 40 79 8 150 The immunization program implemented by the government is very effective 18 45 75 12 150 If I provide immunizations for my child, it means I also take care of the health of the people around me 21 39 82 7 150 The immunization program provided by the government is expected to be very useful 19 42 79 10 150 The latest vaccine products are more dangerous than the old vaccines products 22 61 61 6 150 Information about immunizations that I obtain from health workers can be trusted 14 66 61 8 150 Immunization is the best way to protect my child from illness 20 40 78 12 150 I did what the doctor suggested to immunize my child 17 46 79 8 150 I am worried about the serious side effects caused by immunization 43 70 32 5 150 My child does not need immunizations for PD3I or vaccine- preventable diseases (tuberculosis, polio, hepatitis B, pertussis, diphtheria, measles, and tetanus) because the diseases are now rare 18 76 47 9 150 JURNAL NERS http://e-journal.unair.ac.id/JNERS | 43 (Pelčić et al., 2016). Basically, religion is not in contradiction with vaccination and public health. It is only individual parents or religious leaders and their questionable interpretations of religious practices that are opposed to vaccination since no religion has such intention. There have not been many studies linking the relationship of racial disparities and vaccine hesitancy. This study shows that ethnicity is not related to vaccine hesitancy. This is not in line with the results of a previous study conducted by Crouse Quinn in 2018 which stated that there are significant racial differences in vaccine attitudes, risk perception, trust, hesitancy and confidence. They concluded that racial factors can be a useful new tool for understanding and addressing attitudes toward vaccine behavior (Crouse Quinn et al., 2018). This study also explains that there is no relationship between education level and income on vaccine hesitancy. Previous studies have reported that parents with low levels of education obtain less information about vaccines compared to parents with high levels of education (Kumar et al., 2016). Meanwhile, another study conducted by Opel showed that parents with higher levels of education were nearly four times likely to be concerned about the safety of vaccines than those with lower levels of education. Highly educated people may have thought seriously about vaccination issues from the internet and social media, in which anti-vaccination groups are abundant (Dubé et al., 2013). This study shows that the immunization hesitancy is not affected by parental income levels as well. Some studies revealed that parents of lower-income brackets have been shown in some studies to have greater levels of concern about the safety and necessity of vaccines compared to those with higher socioeconomic status. However, in another study, parents of higher-income brackets are more than two times likely to be concerned that injections might not be safe than parents of lower-income brackets. The apparent contradiction could be related to differing perceptions of what “vaccine safety” means among parents from different socioeconomic backgrounds (Gowda & Dempsey, 2013) This study suggests that the feeling of vulnerability to PD3I or vaccine-preventable diseases in parents and the belief that PD3I can have a serious impact on the health of their children is related to immunization hesitancy in parents. Parents’ perceptions on the prevalence of disease influence parents’ decisions on whether or not to obtain a vaccine. The PD3I can affect anyone; therefore, according to them, infectious diseases that can be contagious should be prioritized for vaccination. It is the same for the severity of PD3I, in which the severity of a disease could be quantified by how long the child would be sick, or if the disease would result in disabilities or long-term effects. These results show that mothers who have a high awareness of the risk of PD3I require more compensation to accept vaccines than mothers who have less awareness of that issue. Table 3. The results of univariate analysis Independent Variables Vaccine hesitancy Sig. Coefficient Correlation Refuser Hesitance Acceptor Religion 0.148 -0.119 Islam 26 88 32 Christian - 2 1 Catholic - - 1 Ethnicity 0.127 0.125 Java 21 80 32 Madura 2 2 - Batak 2 3 1 Chinese - 2 1 Osing - 2 - Balinese 1 1 - Level of education 0.560 -0.097 SD - 2 1 SMP - - 1 SMA 9 31 14 PT 18 57 17 Level of income 0.560 0.048 <2.500.000 11 41 17 >2.500.000 15 48 17 Perceived Susceptibility 0.000 0.323 High 3 28 22 Middle 16 44 9 Low 7 18 3 Perceived Severity 0.000 0.292 High 16 74 33 Middle 3 - - Low 7 16 1 A. N. IZZATI ET AL. 44 | pISSN: 1858-3598  eISSN: 2502-5791 CONCLUSION This study implies that what influences immunization hesitancy to parents is their perception of the possibility of PD3I and the seriousness of the disease. The results of the study assess decision-makers in the governmental organization and all health workers need to confirm to the community about the possibility of PD3I spread and the serious impacts that result from it because, in reality, demographic characteristics have no impact on immunization hesitancy. This study is just a first step into studying vaccine hesitancy in mothers who join the anti- vaccine group on Facebook social media in Indonesia. More studies are required to analyze other factors that can influence immunization hesitancy among mothers in other communities in the real world. CONFLICT OF INTEREST No conflict of interest has been declared. 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