Academic Journal
Προβολή σε EDS

Dose-specific childhood vaccine refusal in Balıkesir, Türkiye (2024): a population-based surveillance analysis.

Λεπτομέρειες βιβλιογραφικής εγγραφής
Τίτλος: Dose-specific childhood vaccine refusal in Balıkesir, Türkiye (2024): a population-based surveillance analysis.
Συγγραφείς: Keskin S; Balıkesir Karesi Provincial Directorate of Health, Balıkesir, Türkiye., Temizer M; Department of Public Health, School of Medicine, Manisa Celal Bayar University, Manisa, Türkiye.
Πηγή: The Turkish journal of pediatrics [Turk J Pediatr] 2026 Feb 27; Vol. 68 (1), pp. 25-37. Date of Electronic Publication: 2026 Feb 27.
Τύπος έκδοσης: Journal Article
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: Hacettepe University, Institute of Child Health Country of Publication: Turkey NLM ID: 0417505 Publication Model: Electronic Cited Medium: Internet ISSN: 2791-6421 (Electronic) Linking ISSN: 00414301 NLM ISO Abbreviation: Turk J Pediatr Subsets: MEDLINE
Imprint Name(s): Publication: Ankara : Hacettepe University, Institute of Child Health
Original Publication: Ankara : Hacettepe Medical Center
Ιατρικοί όροι (MeSH): Vaccination Refusal*/statistics & numerical data , Vaccination Hesitancy*/statistics & numerical data, Turkey/epidemiology ; Humans ; Infant ; Child, Preschool ; Population Surveillance ; Female ; Male ; Immunization Schedule ; Infant, Newborn
Περίληψη: Background: Vaccine hesitancy has intensified since COVID-19. In Türkiye, a performance-based family medicine system provides free vaccines. Before May 2024, physicians could remove refusals from metrics tied to pay deductions, obscuring true rates. A new policy mandating documentation created a natural experiment. We used population-based data to quantify these previously hidden dose-specific refusal rates across the childhood schedule.
Methods: We conducted a population-based ecological analysis of monthly dose-specific refusals among children aged 0-59 months in Balıkesir Province, in 2024. Refusals were extracted from Performance Exception Forms. Rates were calculated per 1,000 target children (Wilson 95% confidence intervals [CI]s), using populations derived from Turkish Statistical Institute counts. To quantify the policy's impact, we fitted an interrupted time-series regression with a fixed breakpoint at May 2024. This model estimated the baseline level and slope (January-April) and compared them to the immediate level shift and new monthly slope post-reform (May-December).
Results: Of 3,584 missed-dose exceptions, 3,002 (83.8%) were refusals. The aggregate refusal rate was 3.9 per 1,000 (January-April) versus 21.6 per 1,000 (May-December), while the rate of on-schedule vaccinations decreased from 99.3% to 97.5%. Segmented regression indicated a baseline of 2.6 per 1,000 and a post-policy level increase of 13.7 per 1,000 (p=0.005); pre- and post-policy monthly slopes were not significant. Refusals concentrated in booster and later-scheduled doses (18-48 months), whereas primary-series doses showed lower, comparatively stable rates. Notably, refusal for the second measles-mumps-rubella dose (MMR-II, 48 months) rose toward year-end, reaching 47.4 per 1,000 in December (95% CI, 35.1-63.6).
Conclusions: Mandatory documentation exposed substantial under-ascertainment of parental refusal in performance-based records. Refusal is disproportionately clustered at booster and later-childhood visits, with MMR-II approaching herd-immunity margins. Programmatically, pediatric booster encounters are key leverage points for targeted counseling, and sustained, transparent surveillance as enabled by the new policy, is essential for early signal detection and response.
References: Shattock AJ, Johnson HC, Sim SY, et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. Lancet 2024; 403: 2307-2316. https://doi.org/10.1016/S0140-6736(24)00850-X.
Galagali PM, Kinikar AA, Kumar VS. Vaccine Hesitancy: Obstacles and Challenges. Curr Pediatr Rep 2022; 10: 241-248. https://doi.org/10.1007/s40124-022-00278-9.
Aguinaga-Ontoso I, Guillen-Aguinaga S, Guillen-Aguinaga L, et al. The Impact of COVID-19 on DTP3 Vaccination Coverage in Europe (2012-2023). Vaccines (Basel) 2024; 13: 6. https://doi.org/10.3390/vaccines13010006.
Abenova M, Shaltynov A, Jamedinova U, Semenova Y. Worldwide Child Routine Vaccination Hesitancy Rate among Parents of Children Aged 0-6 Years: A Systematic Review and Meta-Analysis of Cross-Sectional Studies. Vaccines (Basel) 2023; 12: 31. https://doi.org/10.3390/vaccines12010031.
Eryurt MA, Yalçin SS. Zero-dose children in Turkey: regional comparison of pooled data for the period 1990 to 2018. BMC Infect Dis 2022; 22: 421. https://doi.org/10.1186/s12879-022-07416-0.
Gür E. Vaccine hesitancy - vaccine refusal. Turk Pediatri Ars 2019; 54: 1-2. https://doi.org/10.14744/TurkPediatriArs.2019.79990.
Kurt O, Küçükkelepçe O, Öz E, Doğan Tiryaki H, Parlak ME. Childhood Vaccine Attitude and Refusal among Turkish Parents. Vaccines (Basel) 2023; 11: 1285. https://doi.org/10.3390/vaccines11081285.
Birinci Ş. A Digital Opportunity for Patients to Manage Their Health: Turkey National Personal Health Record System (The e-Nabız). Balkan Med J 2023; 40: 215-221. https://doi.org/10.4274/balkanmedj.galenos.2023.2023-2-77.
Karaşahin EF, Turfan O, İbişoğlu B, Karaşahin Ö, Bedir G. A Rural-Urban Comparison of Performance-Based Primary Health Care Services in Erzurum. International Journal of Health Services Research and Policy 2023; 8: 126-138. https://doi.org/10.33457/ijhsrp.1294640.
Hacettepe University Institute of Population Studies. 2018 Turkey Demographic and Health Survey. 2019. Available at: https://dhsprogram.com/publications/publication-FR372-DHS-Final-Reports.cfm (Accessed on July 22, 2025).
Özlem A, Özlem A, Koçak M, Mehmet N. Prevalence of Turkish Parent Refusal and Hesitance Rate and Its Associated Factors in Childhood Vaccination. Malaysian Journal of Health Sciences 2022; 20: 11-22. https://doi.org/10.17576/JSKM-2022-2002-02.
Soysal G, Akdur R. Investigating Vaccine Hesitancy and Refusal Among Parents of Children Under Five: A Community-based Study. The Journal of Current Pediatrics 2022; 20: 339-348. https://doi.org/10.4274/jcp.2022.01488.
Yalçin SS, Kömürlüoğlu A, Topaç O. Rates of childhood vaccine refusal in Turkey during 2016-2017: Regional causes and solutions. Arch Pediatr 2022; 29: 594-598. https://doi.org/10.1016/j.arcped.2022.06.005.
TURKSTAT. The Results of Address Based Population Registration System, 2024. 2025. Available at: https://data.tuik.gov.tr/Bulten/Index?p=The-Results-of-Address-Based-Population-Registration-System-2024-53783.
Health Directorate of Balıkesir. Performance Exception Forms. 2025. Available at: https://balikesirism.saglik.gov.tr/arama?_Dil=1&p=performans (Accessed on Mar 24, 2025).
TURKSTAT. Birth Statistics, 2023. 2024. Available at: https://data.tuik.gov.tr/Bulten/Index?p=Birth-Statistics-2023-53708.
Republic of Türkiye Ministry of Health. Performance Exception Committee Procedures and Principles “Performans İtiraz Komisyonu Usulü ve Esasları”. 2024. Available at: https://archive.md/zPHda (Accessed on Mar 18, 2025).
Baysan C, Yavaş SP, Uğur Karabat M. Examination of parents refusing administration of childhood vaccinations: Turkey example. CHILDS Health 2021; 16: 218-224. https://doi.org/10.22141/2224-0551.16.3.2021.233906.
Terzi Ö, Gülen EN, Dündar C. The causes of parental vaccine refusal: results of a survey from Giresun, Turkey. Turk J Pediatr 2021; 63: 618-625. https://doi.org/10.24953/turkjped.2021.04.009.
ECDC. Immunisation information systems in the EU and EEA - Results of a survey on implementation and system characteristics. Stockholm: ECDC; 2017. Available at: https://www.ecdc.europa.eu/en/publications-data/immunisation-information-systems-eu-and-eea.
Turcotte-Tremblay AM, Spagnolo J, De Allegri M, Ridde V. Does performance-based financing increase value for money in low- and middle- income countries? A systematic review. Health Econ Rev 2016; 6: 30. https://doi.org/10.1186/s13561-016-0103-9.
Aile Hekimleri Dernekleri Federasyonu. Aşı Redleri Konusunda Bakanlığa Başvurumuzu Yaptık. 2024. Available at: https://www.ahef.org.tr/detay.aspx?ID=3194 (Accessed on Oct 27, 2025).
Patel C, Rendell N, Sargent GM, et al. Measuring National Immunization System Performance: A Systematic Assessment of Available Resources. Glob Health Sci Pract 2023; 11: e220055. https://doi.org/10.9745/GHSP-D-22-00555.
Bussink-Voorend D, Hulscher MEJL, Akkermans R, Krom A, Hautvast JLA. Vaccine hesitancy among Dutch parents of newborn children and its associated characteristics, values and uptake of vaccines. Vaccine 2025; 59: 127244. https://doi.org/10.1016/j.vaccine.2025.127244.
Magyar R, Voitl PK, Voitl JJM, Diesner-Treiber SC. Vaccine hesitancy among parents of children in their first two years of life. Front Public Health 2024; 12: 1438737. https://doi.org/10.3389/fpubh.2024.1438737.
Macedo TRO, Borges MFSO, Silva IFD, et al. Vaccination coverage, barriers and vaccine hesitancy in children up to 24 months old: a population survey in a state capital in the Western Amazon. Epidemiol Serv Saude 2024; 33(spe2): e20231295. https://doi.org/10.1590/s2237-96222024v33e20231295.especial2.en.
Hakim M, Ali F, Zala , Pervaiz A, Afaq S, Haq ZU. Prevalence and associated factors of parental refusal rates for routine immunisation: a cross-sectional study in Peshawar, Khyber Pakhtunkhwa, Pakistan-2024. BMC Public Health 2025; 25: 369. https://doi.org/10.1186/s12889-025-21388-1.
Bhatnagar B, Diallo G. Childhood vaccination rates lag in Europe - fueling further resurgence of measles and whooping cough. Copenhagen, Geneva: WHO Joint News Release; 2025. Available at: https://www.who.int/europe/news/item/15-07-2025-childhood-vaccination-rates-lag-in-europe---fueling-further-resurgence-of-measles-and-whooping-cough (Accessed on Aug 7, 2025).
World Health Organization (WHO). WHO Immunization Data portal - Global: Immunization Data. 2025. Available at: https://immunizationdata.who.int (Accessed on Aug 7, 2025).
Faria LB, França AP, Moraes JC, Donalisio MR. Vaccination Barriers in Brazil: Exploring Hesitancy, Access, and Missed Opportunities in a Cohort of Children (2017-2018)-National Vaccination Coverage Survey Results (2020-2021). Vaccines (Basel) 2025; 13: 516. https://doi.org/10.3390/vaccines13050516.
MacKay H, Gretton JD, Chyderiotis S, et al. Confidence and barriers: Analysis of factors associated with timely routine childhood vaccination in Canada during the COVID-19 pandemic. Vaccine 2024; 42: 126236. https://doi.org/10.1016/j.vaccine.2024.126236.
Minta AA, Ferrari M, Antoni S, et al. Progress Toward Measles Elimination - Worldwide, 2000-2023. MMWR Morb Mortal Wkly Rep 2024; 73: 1036-1042. https://doi.org/10.15585/mmwr.mm7345a4.
Baumgaertner B, Ridenhour BJ, Justwan F, Carlisle JE, Miller CR. Risk of disease and willingness to vaccinate in the United States: A population-based survey. PLoS Med 2020; 17: e1003354. https://doi.org/10.1371/journal.pmed.1003354.
Gowda C, Dempsey AF. The rise (and fall?) of parental vaccine hesitancy. Hum Vaccin Immunother 2013; 9: 1755-1762. https://doi.org/10.4161/hv.25085.
Su Z, Cheshmehzangi A, McDonnell D, da Veiga CP, Xiang YT. Mind the “Vaccine Fatigue”. Front Immunol 2022; 13: 839433. https://doi.org/10.3389/fimmu.2022.839433.
Yalçin SS, Bakacak AG, Topaç O. Unvaccinated children as community parasites in National Qualitative Study from Turkey. BMC Public Health 2020; 20: 1087. https://doi.org/10.1186/s12889-020-09184-5.
Bağ Ö, Güney SA. Vaccine refusal risk factors among parents of children with autism spectrum disorders. Turk J Pediatr 2023; 65: 218-226. https://doi.org/10.24953/turkjped.2022.291.
Kurpas D, Stefanicka-Wojtas D, Soll-Morka A, et al. Vaccine Hesitancy and Immunization Patterns in Central and Eastern Europe: Sociocultural, Economic, Political, and Digital Influences Across Seven Countries. Risk Manag Healthc Policy 2025; 18: 1911-1934. https://doi.org/10.2147/RMHP.S519479.
Hermawan A, Irawan IR, Widiyanti M, Rosnani R, Arifin H. Association of socio-demographic factors with measles vaccination coverage among Indonesian children aged 12-23 months: a nationwide study. Turk J Pediatr 2025; 67: 304-316. https://doi.org/10.24953/turkjpediatr.2025.5886.
Contributed Indexing: Keywords: booster doses; childhood immunization; health policy; interrupted time-series; surveillance; vaccine hesitancy
Entry Date(s): Date Created: 20260323 Date Completed: 20260713 Latest Revision: 20260713
Update Code: 20260714
DOI: 10.24953/turkjpediatr.2026.6792
PMID: 41871555
Βάση Δεδομένων: MEDLINE
Περιγραφή
ISSN:2791-6421
DOI:10.24953/turkjpediatr.2026.6792