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Factors related to parents’ decision not to vaccinate their children
Factores relacionados con la decisión de los padres de no vacunar a sus hijos
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Necesidad de nuevos enfoques" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1664 "Ancho" => 2538 "Tamanyo" => 257582 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Influenza incidence in the hospital's catchment area and distribution of vaccinated HCW and influenza isolated patients per week. 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"apellidos" => "Díaz Molina" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S244514602030011X?idApp=UINPBA00004N" "url" => "/24451460/0000002100000001/v4_202105130819/S244514602030011X/v4_202105130819/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2445146020300091" "issn" => "24451460" "doi" => "10.1016/j.vacune.2020.05.004" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "149" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Vacunas. 2020;21:1-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Premature vaccination. 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Díaz Seoane, C. Berbel Hernández, M. Allué Tango, C. García Rodriguez, P. Sanz López, M.I. Pérez Martín, M.S. Gutiérrez Pérez" "autores" => array:7 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Díaz Seoane" "email" => array:1 [ 0 => "diazseoanem@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Berbel Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Allué Tango" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "García Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "P." "apellidos" => "Sanz López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M.I." "apellidos" => "Pérez Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "M.S." "apellidos" => "Gutiérrez Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Preventiva, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio Territorial de Sanidad, Sección de Epidemiología, Junta de Castilla y León, Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Factores relacionados con la decisión de los padres de no vacunar a sus hijos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1075 "Ancho" => 2179 "Tamanyo" => 131332 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Distribution of the adapted questionnaire scores on the opinions of the case and control groups on vaccination.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vaccination, together with improved hygiene conditions among the general population, has proven to be the most effective public health intervention in the prevention of diseases throughout history. Although much has been achieved, several difficulties remain, including the anti-vaccination movements.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> These movements are not new. Indeed, since its beginnings with smallpox, vaccination has aroused fear from certain groups.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the mid 20th century England introduced obligatory vaccination against smallpox from 3 months of age.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> Some of the population regarded this as an attack against individual freedom, which led to the first anti-vaccination movements. The reasons argued by these groups did not differ much from those used currently to uphold anti-vaccination movements: fear of the adverse effects, the toxicity of certain components, doubts regarding efficacy, etc.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Of note is the fraudulent Wakefield publication associating autism with the MMR vaccine.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> Although the journal publicly retracted this<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> and it was proven that fraud had been committed by the author for financial reasons, some anti-vaccination movements today still base their ideas on the arguments contained in the Wakefield publication.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 2012, the <span class="elsevierStyleItalic">Strategic Advisory Group of Experts-Working Group</span> (SAGE-WG) on the reluctance to vaccinate defined the concept of <span class="elsevierStyleItalic">vaccine hesitancy</span> as delayed acceptance or outright rejection of vaccination, despite its availability, and its determinants according to two conceptual models.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The World Health Organisation (WHO) classified vaccine hesitancy as one of the ten 2019 Public Health problems, which gives an indication of the magnitude of the situation worldwide.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> Western societies’ perception of low risk to disease could be linked to this rejection to some extent. In places where the rate of immune-preventable diseases has considerably diminished (or even been eliminated) the population may lose their reference of the effects of this type of diseases, and focus singularly on the possible side effects of vaccines.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This study was designed in order to determine the main reasons why in recent years some families have rejected vaccination in the province of Valladolid and to compare certain characteristics between families who rejected a vaccine and families who adhered to the vaccination schedule.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">A case-control study was conducted in the province of Valladolid, where boys and girls who had been born between January 2012 and March 2019 were selected and where there was proof that their parents had rejected one or more vaccines.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The database for selecting the cases was obtained from the Vaccination Registration (REVA for its initials in Spanish) programme from the province of Valladolid. A sample was not selected, all cases were accessed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">For case selection the boys or girls for whom only the 13-valent pneumococcal vaccine had been rejected when it was not financed were excluded. The parents were contacted by phone, using the number registered in REVA and if there was no response after 3 attempts they were also excluded from the sample. Other reasons for exclusion were explicit rejection to respond, unavailable phone number or when the boy or girl had been correctly vaccinated against disease (a recording error). The brothers or sisters of a case, with the same parent, were also excluded.</p><p id="par0050" class="elsevierStylePara elsevierViewall">For selection of the control group children who had been correctly vaccinated were paired with each selected case by age (±1 month), sex and basic health area. From the list obtained the first 4 were chosen, provided there was a telephone number, and one control per case was chosen. If after 3 attempted telephone calls there was no response, we passed onto the second case, and so on and so forth (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">A structured questionnaire was created to collect socio-demographic variables, including the age, civil status, profession and level of education of both parents, number of members in the family, the reason for non vaccination of the child, the sources of information used, the adverse reactions observed in their environment, the use of alternative therapies, and breastfeeding. An evaluation of vaccine hesitancy was made using an adaptation of the Parent Attitudes about Childhood Vaccines (PACV)<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">9,10</span></a> questionnaire.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Quantitative variables were presented with their mean and standard deviation and qualitative variables with their frequency distribution.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The measure of association used was the odds ratio (OR), with estimation of statistical significance through its confidence interval (CI). All calculation was performed with the StatCalc module of the Epiinfo 7.2.0.1 programme and with SPSS Statistics version 22.0.0.0 software.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Pearson's chi-squared test was used to analyse the association of the qualitative variables. If the number of cells with expected values under 5 was higher than 20%, the exact Fisher test was used, or the likelihood ratio test for variables with over two categories.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The Students <span class="elsevierStyleItalic">t</span>-test was used for comparison of quantitative values.</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">p</span> values where <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05 were considered statistically significant.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 95 cases were found where at least one vaccine had been rejected. Of these, 82 (86.3%) were selected. Since only the mothers and fathers who agreed to respond to the survey were accepted, the final sample was of 30 parents (31.6%).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding the number of vaccines rejected, 51.9% rejected 2 or more vaccines, whilst 48.1% rejected only one, with the most frequently rejected vaccine being that of chickenpox (stating they would prefer for the child to have the disease).</p><p id="par0095" class="elsevierStylePara elsevierViewall">In both the controls and the cases the majority of those who responded were the mothers (70% and 83.3%, respectively).</p><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding level of education, 63.8% of cases had received a higher or university education compared with 55.1% of the controls (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These differences were not statistically significant. The percentage of people who had received a basic education was higher in the control group (26.5% compared with 10.7% of the cases).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The mean age of the parents was considerable higher in the case group (43 years of age) than in the control group (39 years of age) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding civil status, the highest percentage in both groups were married, at 62.1% and 65.7% respectively (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). No statistically significant differences were observed (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.23).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Few differences were found between the case group and the control group regarding number of family members (mean of 3.8 and 3.9 members, respectively).</p><p id="par0120" class="elsevierStylePara elsevierViewall">In this study results revealed that 75% of the cases had used homeopathy or some other type of alternative therapies at least once, whilst only 34% of the control group had used them. These differences were statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001). Cases and controls were compared with the observation that there was a statistically significant association between the use of homeopathy and the risk of being a case (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.75, 95% CI: 1.9 to 17.34).</p><p id="par0125" class="elsevierStylePara elsevierViewall">In our study, the mother of one case stated that her reason for nonvaccination was the insistence of her naturopath that she should not vaccinate her child. The mother had the child vaccinated later on.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Regarding breastfeeding, 96.4% of the cases and 84.8% of the controls breastfed their child, and there were no statistically significant differences here (difference: 11.58%, 95% CI −2% to 26%). The mean number of months of breastfeeding was 20.1 for the cases (<span class="elsevierStyleItalic">s</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.7) and 15.3 for the controls (<span class="elsevierStyleItalic">s</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12.7), with this difference not being statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.13).</p><p id="par0135" class="elsevierStylePara elsevierViewall">The main source of vaccination information for 55% of the cases was the doctor or paediatrician. Other consulted sources were medical literature, medical articles or sources of alternative therapy. They stressed their perception of the latter sources being meticulous. For the controls, the immense majority of them referred to the doctor or the paediatrician as the main source of information (94.3%), with differences being statistically significant here (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.003).</p><p id="par0140" class="elsevierStylePara elsevierViewall">When asked to rank the different sources of information (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) from more to less trustworthy (with 1 being the most trustworthy source and 5 the least), in both groups the healthcare professionals ranked first (1.4 mean in the cases and 1.1 in the controls).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The most frequently given reason by the case group for not vaccinating their children was the idea that “children are given too many vaccines” and that “vaccines are unnecessary” (30%). The second idea was that it is better to have the disease (20%). In the subgroup of respondents who only rejected the chickenpox vaccine, they stated that it was a disease everyone had had and it was unnecessary to be vaccinated against it. Other reasons for not being vaccinated were “they give vaccines very early to children whose immune system is immature and unprepared for them” (13.3%); “the vaccination schedule changes all the time” (10%); that “vaccines contain heavy metals” (6.7%); “they lead to autism”(6.7%); “they are unsafe and there are more risks than benefits” (6.7%), or “because of the parents’ own lifestyle” (6.7%). Lastly, a few stated the reason as “fear of side effects”, “lack of efficacy” and “pressure from their naturopath to not vaccinate”.</p><p id="par0150" class="elsevierStylePara elsevierViewall">When asked whether anyone in their environment had had a health problem following vaccination 60.7% of the cases confirmed they had, compared with 14.3% of controls. The cases described these health problems in relation to the appearance of diseases such as autism, cerebral palsy and other types of serious pathologies, which were never mentioned by the control group. These differences were statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001).</p><p id="par0155" class="elsevierStylePara elsevierViewall">The adapted PACV questionnaire contained 12 items with scores from 1 to 5, with a score of 1 being the most “anti-vaccine” score and 5 being the most “pro-vaccine” score (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The mean of the cases was 2.6 compared with 3.9 of the controls, with these differences being statistically significant in each of the items and in the total mean (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). The cases had a lower mean which is in keeping with their more disinclined attitude towards vaccination (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">With regard to the parents’ intention to vaccinate their next child, should they have one, or not, 21% of the cases and 94.1% of the controls (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001) said they would.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The level of agreement between the parents regarding the decision to vaccinate or not was also explored, with 85.2% in agreement among the cases and 97% among the controls (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001).</p><p id="par0170" class="elsevierStylePara elsevierViewall">Lastly, after completing the questionnaire it was suggested to the case study group that they consult a doctor to resolve their doubts about vaccination. Three accepted. Finally, only one family consulted a doctor. A health education session was given to these parents. During consultation, questions were asked regarding numerous false myths about vaccination which they had already been shown (autism, side effects, heavy metals, lack of efficaciousness…). The parents were very grateful to have been given this information and for the help received. One month later, the vaccination schedule of their child was reviewed, but no recording of any vaccine administered has been made to date.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0175" class="elsevierStylePara elsevierViewall">According to data from the Ministry of Health, Spain has a high vaccination coverage for children, with figures over 95% in the last 10 years for the first vaccination.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> In the province of Valladolid, a total of 30,754 children born between 2012 and March 2019 were registered in RENA (Birth registry in Castilla and Leon). Of these, 95 children were registered with one or more vaccines not administered due to the refusal of their parents (.31%). Although this is still a minority group in Spain, it is of note that currently in neighbouring countries (Italy, France etc.) there has been an upsurge in diseases such as measles due to the decrease in vaccination coverage.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12–15</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The telephone survey response was considered to fall within the expected rate.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> In general it has been observed that telephone surveys have a lower rate of response to, for example, face-to-face surveys.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> Furthermore, this was a highly minority subgroup within the general population, and this, combined with the idea of certain distrust towards mainstream medicine, may have limited participation.</p><p id="par0185" class="elsevierStylePara elsevierViewall">In previous studies the parents who rejected one or several of the vaccines recommended for their children<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> shared certain characteristics. In our study certain differences were also observed. However an attempt was made to find common characteristics which could help to address the problem of non vaccination due to rejection by the families.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Regarding level of education, other authors did not observe a clear pattern.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">18,19</span></a> Generally it has been observed that a higher level of education is associated with greater trust of vaccines. However, recent studies in some countries have observed that the behaviour of this subgroup may be similar to that of people with a lower educational level.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> In our study only minor, insignificant differences were found. It should be taken into consideration that the selection of the control group was made through pairing age, sex and healthcare centre with each case. This may have led to a level of education variable bias due to health centre location.</p><p id="par0195" class="elsevierStylePara elsevierViewall">With regard to alternative therapies, the control group was less interested in the use of this type of therapies. However, due to the reduced sample size, we would recommended further research into this issue.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Our research study also focused on breast milk, on the supposition that parents who are recalcitrant about vaccinations could present with a more naturist focus on health and be in favour of prolonging breastfeeding. No significant differences were found but again the sample size may have been relevant here.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Also of interest was exploration of who the families trusted for information about vaccines. It was highly striking that over half of the cases mentioned the doctor as the main source of information whilst the attitude of these parents was a distrust of mainstream medicine.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The difference found in the perception of each group towards possible side effects of the vaccines was foreseeable, as was the presence of false myths in the cases.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Lastly, in our study we perceived that the parents who had doubts regarding the vaccination of their children often described they felt they were being judged by healthcare professionals. This made them all the more reluctant to consult them, and perhaps found greater comprehension from other types of non mainstream medicine.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> A healthcare approach focused on reaching agreements between parents and doctors, without entering into value judgments, could be a good starting point.</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Strengths</span><p id="par0220" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0225" class="elsevierStylePara elsevierViewall">Little literature exists in this respect in Spain, so this study provides further knowledge on this issue.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">This is a case-control study, focused on the difference between parents in favour of and parents against vaccination, with some differences being statistically significant</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">Healthcare education was offered, but only one family decided to receive it.</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Limitations</span><p id="par0240" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0245" class="elsevierStylePara elsevierViewall">The main limitation of this study is the small sample size obtained. It would be relevant to increase the sample by increasing the geographical study area.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">Selection bias: the people who responded to the survey may have had different characteristics from the people who did not respond to the survey.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">Our sample was taken from the REVA programme where explicit parental rejection of vaccination had been recorded. It is possible that a subgroup of parents exist who would also reject vaccination but which is not contained in this register because they did not consult a doctor and therefore did not state their disagreement with vaccinating their children. This would therefore be recorded as a vaccine which had not been received, not as a vaccine that had been rejected. As a result, this hypothetical subgroup would not be present in our sample.</p></li></ul></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0260" class="elsevierStylePara elsevierViewall">A very small percentage of children in the province of Valladolid born between 2012 and March 2019 were not administered one or several recommended vaccines due to the explicit rejection by their parents (.31%).</p><p id="par0265" class="elsevierStylePara elsevierViewall">In our study the parents who rejected vaccination manifested higher distrust of the mainstream healthcare system than those parents who were in favour of vaccination: using alternative therapies, such as homeopathy, describing more adverse reactions in their environment resulting from vaccination, etc. However, 54% cited their doctor as the main source of information.</p><p id="par0270" class="elsevierStylePara elsevierViewall">The most frequently given reason why parents refused to vaccinate their children on occasion was that these vaccines were unnecessary and that children were administered too many vaccines (30%).</p><p id="par0275" class="elsevierStylePara elsevierViewall">In our study we observed that the use of homeopathy was a risk factor in deciding not to vaccinate (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.75). However, our sample size was small, and this issue requires further investigation.</p><p id="par0280" class="elsevierStylePara elsevierViewall">A partnership approach between parents and doctor would be a good starting point for addressing this type of patient.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0285" class="elsevierStylePara elsevierViewall">There were no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1510433" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results and discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1370086" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1510432" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados y discusión" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1370087" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:3 [ "identificador" => "sec0030" "titulo" => "Discussion" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Strengths" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-06" "fechaAceptado" => "2020-03-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1370086" "palabras" => array:4 [ 0 => "Anti-vaccines" 1 => "Vaccine coverage" 2 => "<span class="elsevierStyleItalic">Vaccine hesitancy</span>" 3 => "Homeopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1370087" "palabras" => array:4 [ 0 => "Antivacunas" 1 => "Cobertura vacunal" 2 => "<span class="elsevierStyleItalic">Vaccine hesitancy</span>" 3 => "Homeopatía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although vaccination has proven to be one of the most effective public health interventions for disease prevention, a small section of the population presents the so-called ‘vaccine hesitancy’ or vaccination doubts. It would be interesting to know the possible factors related to rejection of vaccination.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Study of cases and controls in which data have been collected from children registered in the REVA programme in the province of Valladolid with explicit rejection of parents (cases), paired with children of the same age, sex and basic health area that do have been vaccinated (controls). Telephone interview was conducted to obtain sociodemographic factors and opinion on vaccination.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results and discussion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 82 children were selected, of whom 30 parents agreed to take to the survey. 55% of them mention the doctor as the main source of vaccination information, which contrasts with the distrust of the detected system. Statistically significant differences in the perception of vaccination side effects between cases and controls and in the different items were observed. Statistically significant association was observed between the use of homeopathy the risk of being a case (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.75, 95%<span class="elsevierStyleHsp" style=""></span>CI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.9 to 17.34).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Although the number of children not vaccinated by explicit rejection by their parents in Valladolid is very low, it is important to know the reasons for this decision and to make an approach guided by the approach of postures rather than the judgment of values towards these families.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results and discussion" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A pesar de que la vacunación ha demostrado ser una de las intervenciones en salud pública más eficaz para la prevención de enfermedades, un pequeño sector de la población presenta el llamado <span class="elsevierStyleItalic">«vaccine hesitancy»</span> o dudas sobre vacunación. Resultaría interesante conocer los posibles factores relacionados con el rechazo a la vacunación.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de casos y controles en los que se han recogido datos de niños y niñas registrados en el programa REVA en la provincia de Valladolid con rechazo explícito de los padres (casos), emparejados con niños de su misma edad, sexo y zona básica de salud que sí han sido vacunados (controles). Se realizó entrevista telefónica para obtener factores sociodemográficos y opinión sobre vacunación.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados y discusión</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se seleccionaron un total de 82 niños y niñas, de los cuales 30 padres aceptaron contestar a la encuesta. El 55% de ellos mencionan como principal fuente de información en vacunación al médico, lo que contrasta con la desconfianza hacia el sistema detectada. Se observaron diferencias estadísticamente significativas en la percepción de los efectos secundarios de la vacunación entre casos y controles y en los diferentes ítems. Se observó asociación estadísticamente significativa entre el uso de homeopatía y el riesgo de ser caso (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5,75, IC<span class="elsevierStyleHsp" style=""></span>95%<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1,9 a 17,34).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A pesar de que es muy bajo el número de niños no vacunados por rechazo explícito de sus progenitores en Valladolid, es importante conocer los motivos de esta decisión y hacer un abordaje guiado por el acercamiento de posturas en lugar del juicio de valores hacia estas familias.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados y discusión" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Díaz Seoane M, Berbel Hernández C, Allué Tango M, García Rodriguez C, Sanz López P, Pérez Martín MI, et al. Factores relacionados con la decisión de los padres de no vacunar a sus hijos. Vacunas. 2020;21:4–10.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1358 "Ancho" => 2416 "Tamanyo" => 231559 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram of the case selection process.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1299 "Ancho" => 987 "Tamanyo" => 69367 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Level of education of the parents who rejected vaccination for their children born between January 2012 and March 2019 in the province of Castilla and Leon (cases) and the parents who had their children with the same characteristics correctly vaccinated (controls) (%).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1126 "Ancho" => 2190 "Tamanyo" => 77154 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Civil status of the parent respondents (%).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1075 "Ancho" => 2179 "Tamanyo" => 131332 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Distribution of the adapted questionnaire scores on the opinions of the case and control groups on vaccination.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cases \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Controls \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Internet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Media \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.4 (.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Family and friends \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 (.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Healthcare professionals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 (.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Homeopathy or other therapies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.2 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.2 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2594108.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Level of use of different sources of information in case and control groups (from 1st to 5th place).</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The scores are presented as a mean (standard deviation).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cases \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Controls \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 1. More vaccines than are necessary are administered \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 2. They prevent serious disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.8 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4 (.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 3. It is better to have the disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.8 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 4. It is better to have a few vaccines at the same time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 5. I trust my paediatrician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 (.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 6. I can express my doubts to my paediatrician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6 (.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 7. I am concerned about serious adverse effects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.8 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.7 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 8. Vaccines are effective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6 (.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 9. Vaccine-free environment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 (.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 10. Safety of the vaccines \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 (.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 11. Vaccines and autism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1 (.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item 12. In favour of the child vaccination programme \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6 (.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 (.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2594107.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Results from the adapted questionnaire on the opinion of case and control groups on vaccination (scores from 1 to 5).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Movimientos antivacunas: una llamada a la acción" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L. 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