Article
Health Education and Vaccination for the Construction of
Inclusive Societies
Eduardo GarcÃa-Toledano 1
, Ascensión Palomares-Ruiz 2,* , Antonio Cebrián-MartÃnez 2
and Emilio López-Parra 2
Citation: GarcÃa-Toledano, E.;
Palomares-Ruiz, A.;
Cebrián-MartÃnez, A.; López-Parra, E.
Health Education and Vaccination for
the Construction of Inclusive
Societies. Vaccines 2021, 9, 813.
https://doi.org/10.3390/
vaccines9080813
Academic Editor: Brian D. Poole
Received: 26 May 2021
Accepted: 19 July 2021
Published: 22 July 2021
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Attribution (CC BY) license (https://
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4.0/).
1 Department Public health, Childhood Cancer Foundation, 28029 Madrid, Spain; [email protected]
2 Department of Pedagogy, Universidad de Castilla-La Mancha, 02071 Albacete, Spain;
[email protected] (A.C.-M.); [email protected] (E.L.-P.)
* Correspondence: [email protected]
Abstract: Globalization has led to what has happened in a certain part of the world having a
significant and rapid impact on other places, causing significant changes in health problems. In the
last quarter of the 18th century, the history of vaccination began, becoming an effective tool to prevent
and control communicable diseases. This paper proposes an observational research with a crosssectional design to study the importance of health education and vaccination in building inclusive
societies. With a sample of 1000 participants from 76 countries, vaccine awareness and regulation
were analyzed, considering the following variables: gender, age, sector, Human Development Index
(HDI), and continent. The instrument used was a questionnaire (VACUNASEDUCA) developed for
this research and timely validated. As a result, it is highlighted that the profiles of women, people
under 30 years of age, education sector, high Human Development Index, and European continent
are those that most value the importance of raising awareness in society and the regulation of actions
for vaccination compliance. The consequences of “vaccine reluctance†are of concern in every country
on the planet. Therefore, it is concluded that effective and evidence-based communication is key to
allaying fears and promoting acceptance of vaccination around the world, building inclusive societies
in which all citizens enjoy the health benefits.
Keywords: vaccines; public health; vaccine reluctance; education; inclusive societies; COVID-19;
immunization; bootstrap; gender
1. Introduction
In recent decades, globalization has caused events, decisions, and activities happening
in each place on the planet to have a significant and rapid impact elsewhere in the world.
All this leads to a significant change in health problems and societal concerns. Reasonably,
many difficulties have their origins in social factors that cause inequalities in health, but it
should be noted that it is the growing socioeconomic inequalities that generate the greatest
inequalities in health, so that poverty is the main socioeconomic factor that affects the state
of health of people [1]. Indeed, the world is immersed in various challenges, one of the
most significant being the effects of the new technological revolution that is generating the
transformation of humanity. Therefore, the concept of the “fourth industrial revolutionâ€
arises within the framework of the World Economic Forum to refer to changes in the global
economy from the basis of technologies supported by physical systems, biological systems,
digital systems, and their interactions, generating a fundamental change in the way we
live, work, and relate [2].
It should be recalled that, in 1789, Edward Jenner was the first to scientifically demonstrate that people could be protected against smallpox, if exposed to smallpox vaccine [3,4].
However, it should be noted that, a few years earlier, in 1774, there is a reference to the first
person who performed a vaccination; in this case, he vaccinated his family with smallpox
vaccine [5]. Nowadays, vaccines can prevent and control communicable diseases and are
Vaccines 2021, 9, 813. https://doi.org/10.3390/vaccines9080813 https://www.mdpi.com/journal/vaccines
Vaccines 2021, 9, 813 2 of 15
considered essential to deal with emerging infectious diseases; they can immobilize or limit
epidemic outbreaks of these, and combat the spread of antimicrobial resistance. For this
reason, society is demanding that the industry and the scientific community respond with
vaccines, as soon as possible, to the epidemics of H1N1 flu, Ebola, Zika, COVID-19, etc. [6].
As it is known, vaccines are antigenic preparations made up by micro-organisms,
or by part of these, which are modified to lose or attenuate their pathogenic capacity,
and their purpose is to stimulate the individual’s defence mechanisms against infectious
agents. Advances in molecular biology, specifically in the development of recombinant
DNA technology and bioinformatics, have been essential for the evolution of vaccines [7].
Consequently, diseases such as smallpox have been eradicated globally, and other diseases,
such as polio and measles, have been significantly reduced, as have the disabilities and
deaths these diseases can cause. Its effectiveness is evidenced by the fact that, when
immunization coverage decreases, diseases that have not been completely eradicated
rebound, such as measles in Europe in recent years [8] or in the United States, which,
in 2019, reported the highest number of cases since 1992 [9]. Immunization also plays
a key role in achieving UN Sustainable Development Goals (SDG), specifically SDG3,
“Ensuring healthy living and promoting well-being for all at all agesâ€, and contributes to
the achievement of the other 16 SDGs [10].
It should be noted that there is no 100% effective vaccine, nor are they all equally
effective; however, the benefits of vaccines focus on their proven effectiveness, which
is revealed in their behavior in practice and depends, fundamentally, on the immune
capacity of the recipient, the type of vaccine, established schedules, availability, tolerance,
and stability.
Since the creation of the Expanded Immunization Program by the World Health Organization (WHO) in 1974, benefits have been expanded and there is explicit recognition of
the importance of vaccination and its high impact on social welfare. Global Vaccine Action
Plan 2011–2020 (GVAP) [11] was approved by 194 countries in the World Health Assembly.
Consequently, the evaluation of GVAP results in 2019 [12] facilitated the development of
new proposals until 2030. It should be noted that the GVAP increased the visibility of
immunization and assisted in the creation of a high-level political will. Indeed, it created a
common framework for prioritizing, agreeing on activities, and evaluating results. The
Immunization Agenda (AI2030) [12] has designed a comprehensive global vaccine and
immunization strategy for the decade 2021–2030. Reasonably, AI2030 takes advantage of
the lessons derived from GVAP and considers the new and persistent challenges posed by
infectious diseases.
The European Union (EU) carries out public health policies, but there is no common
prevention model. This situation creates inequality to access to immunization among
entire communities of citizens, as evidenced by the COVID-19 pandemic. It should be
noted that each State has specific legislation on vaccination. Although each country’s
vaccination plans are similar, there are significant differences in the vaccines included in
the publicly funded vaccination schedules. In addition, the same vaccines are not given
and not all vaccines are mandatory, as in Spain, where, to date, they are all voluntary in
nature. Each country designs its vaccination strategy with respect to its epidemiological
situation; however, WHO, the EU, and United Nations International Children’s Emergency
Fund (UNICEF) develop global and European prevention and immunization strategies
and plans [13].
Consequently, the AI2030 [12] aims to strengthen existing partnerships, establish new
relationships, and better clarify roles and responsibilities in order to improve the use of
information to drive action and ensure relevant assessments.
Vaccines are an excellent investment generating an improvement in quality of life,
as demonstrated by the Decade of Vaccine Economics project [14], which has been most
evident in the most disadvantaged countries. In addition, as González-GarcÃa points
out [15], more investment would have to be made in research and development, which will
enable humanity to face with hope and strength any biological threats and pandemics that
Vaccines 2021, 9, 813 3 of 15
are to come, which would mean an excellent investment in the future, thus improving the
quality of life around the world.
WHO [16] considers vaccination, along with “clean waterâ€, as one of the biggest
public health successes, and scientific evidence has shown that the benefits of vaccination
outweigh the unusual adverse effects. However, since the onset of vaccines, out of fear
or carelessness, there are detractors of these, but the fashion of not vaccinating and the
anti-vaccine movement began to grow more and more from 1998 onwards, when a doctor,
Andrew Wakefield, presented in the scientific journal The Lancet a study linking autism
with the triple viral vaccine (measles, rubella, and mumps). The study was based on a
very small sample, biased, and without any scientific rigor. As a result of this article, other
studies were conducted with different results, demonstrating that it had been a scientific
fraud [17].
Currently, rejection of vaccination is occupying large spaces for debate and discussion
in the media and social media, in the various areas of society, and in all countries of the
world. There are concerns about how the problem is being raised as, in most cases, it
is reduced to the polarization between pro-vaccines and anti-vaccines without seriously
addressing the issue of vaccination considering the importance of group immunity and
collective health. Vaccination reluctance ranges from acceptance to total rejection, with
different nuances called “vaccine reluctance†[18]. For years, the consolidation of vaccine
rejection has been rated as a growing threat to collective health [19].
The recommendations proposed by WHO [20] focus on the need for a better awareness
of vaccination reluctance, its determinants, and the challenges it poses. It also stresses
the need to improve society’s awareness of the importance of vaccination in order to
improve vaccine acceptance, share effective practices, and develop new tools to assess and
address reluctance. Reasonably, in order to improve society’s awareness, it is essential to
analyze the benefits and effectiveness of vaccines, concerns about their safety, and how
they are perceived in society. Indeed, as Matesanz points out [21], having an effective
vaccine is not an individual solution, but that it is received by the maximum number of
people in the environment to achieve the long-awaited “herd immunity†and that the virus
stops circulating.
It should be emphasized that the information on COVID-19 is overflowing us and relegating to the background the importance of other vaccines that are fundamental to children,
especially for the most vulnerable countries. In addition, as GarcÃa-Toledano [22] points
out, the problem with vaccination programs is that they are linked to constant variations
linked to vaccine availability, distribution, and administration logistics. Therefore, incorrect
communication and co-ordination can show society a negative image of improvisation and
lack of co-ordination that do not benefit awareness of the importance of vaccination.
It should be noted that, possibly, in the absence of regulation by administrations over
the past two decades, the number of parents who choose not to vaccinate their children
has increased. This increase can also be affected because the propaganda that opposition
groups broadcast today has much more advanced and powerful information transmission
tools every day, through social networks that facilitate the distribution of their opinion to a
large number of people in a short period of time. In addition, some public figures publicly
support this non-vaccination movement, leading to greater confusion in the population.
Fortunately, the Spanish population is generally highly aware of vaccination, reaching
immunization rates of 96% in childhood. This figure has fallen slightly in recent years,
but it may not be as a result of these opposition associations, but also for socioeconomic
reasons in certain marginal groups, so it is important to carry out educational projects
aimed at these sectors of the population [22].
If we focus on the current situation caused by COVID-19, WHO [20] has stated that,
although coronavirus vaccination has intensified, the world will not achieve collective immunity in 2021. For this reason, internationally renowned organizations, such as the United
Nations Educational, Scientific, and Cultural Organization (UNESCO), WHO, UNICEF, the
Council of Europe, the Organization for Economic Co-operation and Development (OECD),
Vaccines 2021, 9, 813 4 of 15
and the European Commission, indicate that it is essential that schools incorporate health
education into their curriculums as a basic tool for developing healthy lifestyle habits,
increasing the quality of life of schoolchildren and, consequently, working on building a
better world [23].
In the context we find ourselves, our main purpose is to study the importance of
education for health and vaccination, analyze its development, and assess its situation in
the 21st century.
2. Materials and Methods
An observational research was performed using a cross-sectional design which focuses
on the study of health education and vaccination for the construction of inclusive societies.
The awareness and regulation of vaccines (Dimension 1) were, therefore, analyzed with the
aim of responding to problems: P1, society awareness of the importance of vaccination; P2,
regulation of administrations of actions for vaccine compliance.
2.1. Population and Sample
The sample consists of 1000 participants from 76 countries. The distribution of the
participating sample is defined in the results section of the investigation.
The study population is delimited based on the selection criteria of developing their
professional activity in one of the three sectors analyzed: health, education, and economics.
All persons with a job performance not directly linked to these sectors were excluded.
The sample selection followed a non-probabilistic sampling method of an accidental or
consecutive type, consisting of 1000 participants from 76 countries (Figure 1).
Vaccines 2021, 9, x FOR PEER REVIEW 4 of 16
If we focus on the current situation caused by COVID-19, WHO [20] has stated that,
although coronavirus vaccination has intensified, the world will not achieve collective immunity in 2021. For this reason, internationally renowned organizations, such as the
United Nations Educational, Scientific, and Cultural Organization (UNESCO), WHO,
UNICEF, the Council of Europe, the Organization for Economic Co-operation and Development (OECD), and the European Commission, indicate that it is essential that schools
incorporate health education into their curriculums as a basic tool for developing healthy
lifestyle habits, increasing the quality of life of schoolchildren and, consequently, working
on building a better world [23].
In the context we find ourselves, our main purpose is to study the importance of
education for health and vaccination, analyze its development, and assess its situation in
the 21st century.
2. Materials and Methods
An observational research was performed using a cross-sectional design which focuses on the study of health education and vaccination for the construction of inclusive
societies. The awareness and regulation of vaccines (Dimension 1) were, therefore, analyzed with the aim of responding to problems: P1, society awareness of the importance of
vaccination; P2, regulation of administrations of actions for vaccine compliance.
2.1. Population and Sample
The sample consists of 1000 participants from 76 countries. The distribution of the
participating sample is defined in the results section of the investigation.
The study population is delimited based on the selection criteria of developing their
professional activity in one of the three sectors analyzed: health, education, and economics. All persons with a job performance not directly linked to these sectors were excluded.
The sample selection followed a non-probabilistic sampling method of an accidental or
consecutive type, consisting of 1000 participants from 76 countries (Figure 1).
Figure 1.
Figure 1. Nationality of study participants. Source: own elaboration.
Nationality of study participants. Source: own elaboration.
2.2. Variables
The questionnaire used VACUNASEDUCA [24] consists of 12 items: 2 items corresponding to dimension D1 = Awareness and regulation, 4 items corresponding to dimension
D2 = Education and teachers, 2 items corresponding to dimension D3 = Regulation and
obligation, and 4 items corresponding to dimension D4 = Consequences and risks.
Vaccines 2021, 9, 813 5 of 15
As an answer option for each item, a Likert scale of 1 to 3 was raised indicating the
degree of agreement of the participant with the corresponding question; in this way, there
were 12 ordinal variables for each of the items in the questionnaire.
The dependent variable S3t was built by adding the individual ordinal scores for each
of the participants and dividing by 12 to typify it; in this way, we could have a quantitative
dependent variable that came to represent the degree of agreement of each participant with
the 12 items of the questionnaire that would allow us to perform the inferential analysis for
each of the independent variables or factors of the research:
• Gender: independent dichotomic variable with 2 options, G0 = Woman or G1 = Man.
• Age: polyatomic independent variable with 4 options, E1 = Less than 30, E2 = Between
30 and 44, E3 = Between 45 and 59, or E4 = Greater than 60.
• Sector: polyatomic independent variable with 3 options, S1 = Health, S2 = Education, or
S3 = Economy.
• Human Development Index (HDI): polyatomic independent variable with 4 options,
I1 = very high, I2 = high, I3 = medium, or I4 = low.
• Continent: polyatomic independent variable with 5 options, C1 = Europe, C2 = America,
C3 = Asia, C4 = Africa, or C5 = Oceania.
2.3. Instrument
The technique used for data collection was the survey, the instrument chosen being a
questionnaire consisting of 12 items with a Likert scale.
The questionnaire was developed for the purpose of this research, being submitted
to a trial by 15 experts, which allowed Lawshe’s content validity index (CVI) [25] to be
calculated, which suggested a CVI 0.51 when using 14 experts, so there was no need to
remove any items from the initial questionnaire. Table 1 reflects the CVI for each of the
dimensions of the questionnaire, the mean index being 0.96 [26–28].
Table 1. Instrument structure.
Dimension Items α CVI
D1 = Awareness and regulation 1, 2 0.52 0.87
D2 = Education and teachers 3, 4, 5, 6 0.56 0.93
D3 = Regulation and obligation 7, 8 0.57 1
D4 = Consequences and risks 9, 19, 11, 12 0.92 1
Mean 0.64 0.96
Source: own elaboration.
The questionnaire was also validated through exploratory factor analysis. The result
of the Kaiser–Meyer–Olkin KMO test was 0.784, revealing the sample adequacy for performing factor analysis. The result of Bartlett’s sphericity test yielded a significance level of
0.000, which involved suitability for factor analysis. Although the matrix of factorial analysis components did not come out completely “cleanâ€, with 2 items appearing correlated
with 2 factors, the factorial structure obtained was very similar to that initially designed by
GarcÃa Perales et al. [28] and Méndez & Rondón [29].
The reliability of the questionnaire, in the sense of stability of the results, was calculated through the alpha coefficient of Cronbach (α). Table 1 shows the indexes obtained for
each of the dimensions. The mean value for the 4 dimensions was 0.64, being close to the
0.70 limit that Kerlinger et al. [30] set for acceptable consistency.
2.4. Procedure
The questionnaire was prepared between June and July 2019 and was implemented
from September 2019 to March 2020, specifically, of September to December at the headquarters of the WHO Geneva, and from January to March in Spain, in hospitals, universities,
International Congresses of Education, and Congresses and meetings of Medicine.
Vaccines 2021, 9, 813 6 of 15
The questionnaire was completed in a self-administered form, on paper and in person,
in two languages, English and Spanish. There was no time limit, such as the respondents
usually would take between 5 and 10 min, and the pollster was always the same person. The
research was conducted at the beginning of the COVID-19 pandemic and was not affected
by confinement. Anonymity and confidentiality of participants’ data was guaranteed at
all times.
2.5. Data Analisys
In view of noncompliance with the premises of parametric methods, since the sample
distribution did not conform to the normal distribution, it was chosen to use statistical techniques of null models using resampling techniques through the Monte Carlo simulation
method using the bootstrap procedure [31], which can be included within the approach
of resampling data that perform computer simulation processes that are based on the
extraction of a large number of repeated samples from the data themselves, and on which
descriptive and inferential statistical analysis is performed using confidence intervals (ICs)
extracted from the data themselves. This is what distinguishes such new procedures from
classical statistical techniques that are based on theoretical models developed analytically.
Consequently, some authors describe these techniques as intensive computation methods
and are included within a modern statistical approach, competing with the classical mathematical approach [32,33]. This new approach is based on the enormous computing capacity
of modern computers and the sufficiency of the sample to represent or reflect relevant
aspects of the population from which it was extracted, since bootstrap’s method allows
“the maximum from the little information available†to be extracted [34] (p.149).
To analyze whether there were statistically significant differences, an ANOVA test
was chosen for independent samples for each of the independent variables or factors in the
research. The values of the F statistic, significance level p, and effect size measured by eta
squared were obtained using the analysis of the multivariate general linear model of the
SPSS statistical program in version 26. Post hoc tests were conducted assuming not equal
variances using Tamhane’s T2, Dunnett’s T3, Dunnett’s Games–Howell, and Dunnett’s C
statistics, all of which yielded similar results that served to determine the direction column
in the ANOVA tables for each of the factors analyzed.
3. Results
First, Table 2 shows the main characteristics of the sample in relation to gender, age,
HDI, sector. and continent.
In order to contextualize Dimension 1 in the research on the importance of health
education, Table 3 shows the descriptive statistics obtained in the four dimensions of the
questionnaire used.
In Table 3, you can see high results for dimensions D1 = Awareness and regulation and
D2 = Education and teachers, highlighting item P06 that gets the upper mean score (M = 2.86,
SD = 0.44), the highest mean value of the instrument set, and low results for dimensions
D3 = Regulation and obligation and D4 = Consequences and risks by highlighting items P11
and P12 that get the lowest mean score (M = 1.18, SD = 0.42 and 0.43), the lowest mean
value of the instrument assembly.
The mean scores for each dimension were as follows: D1 = Awareness and regulation
(M = 2.81, SD = 0.36), D2 = Education and teachers (M = 2.81, SD = 0.31), D3 = Regulation
and obligation (M = 1.47, SD = 0.59), and D4 = Consequences and risks (M = 1.20, SD = 0.41).
The mean of the questionnaire as a whole was (M = 2.05, SD = 0.22).
As noted, in this work, we will focus on Dimension 1 (Awareness and regulation) with
independent variables: gender, age, sector, HDI, and continent.
3.1. Gender Impact Analysis
In Table 4, the distribution of the sample according to the gender can be observed:
G0 = Woman or G1 = Man for dimension D1.
Vaccines 2021, 9, 813 7 of 15
As can be seen in Table 4, the distribution of the sample according to gender is uneven;
the percentage of women (69.4%) is much higher than that of men (30.6%).
To analyze whether gender differences exist in the questionnaire, an ANOVA was
performed for independent samples. The results are listed in Table 5.
Table 2. Characteristics of the sample.
Sample Characteristics
Gender
Women Men
n % n %
694 69.4% 306 30.6%
Age
−30 30–44 45–59 +60
n % n % n % n %
363 36.30% 348 34.80% 267 26.76% 22 2.20%
IDH
Very High High Medium Low
n % n % n % n %
873 87.3% 85 8.5% 31 3.1% 11 1.1%
Sector
Health Education Economy
n % n % n %
554 55.4% 329 32.9% 117 11.7%
Continent
Africa America Asia Europe Oceania
n % n % n % n % n %
35 3.5% 93 9.3% 40 4% 830 83% 2 0.2%
Source: own elaboration.
Table 3. Counting after the application of the questionnaire.
Scale (n) 95% CI 95% CI
Item and Dimension (D) 1 2 3 n M Lower–Upper SD Lower–Upper
P01. Do you value that society is aware of the
importance of vaccination? 26 174 800 1000 2.77 2.75–2.80 0.48 0.44–0.51
P02. Do you believe that administrations have regulated
actions for vaccine compliance? 14 132 854 1000 2.84 2.81–2.86 0.40 0.37–0.44
D1 = Awareness and regulation 2.81 2.78–2.83 0.36 0.34–0.38
P03. Do you consider that, in your country, the training
of compulsory education teachers (Children and
Primary) provides adequate training on vaccines?
34 131 835 1000 2.80 2.77–2.83 0.48 0.44–0.52
P04. Do you think teachers are aware of the proper use
of vaccines? 27 152 821 1000 2.79 2.77–2.82 0.47 0.43–0.50
P05. Do you think parents know the consequences that
coexistence with other non-vaccinated peers could have
on their children?
35 139 826 1000 2.79 2.76–2.82 0.49 0.44–0.52
P06. Do you believe that teachers at mandatory levels
should receive initial training on health education and
specifically on the vaccination process?
35 74 891 1000 2.86 2.83–2.88 0.44 0.40–0.49
D2 = Education and teachers 2.81 2.79–2.83 0.31 0.28–0.33
P07. Do you think it is necessary for teachers to require
students to have a scheduled vaccination card? 616 183 201 1000 1.59 1.53–1.64 0.80 0.78–0.83
P08. Do you know if there is adequate regulations to
support teachers in the demand to comply with
childhood vaccination?
701 240 59 1000 1.36 1.32–1.40 0.59 0.56–0.62
D3 = Regulation and obligation 1.47 1.44–1.51 0.59 0.56–0.61
Vaccines 2021, 9, 813 8 of 15
Table 3. Cont.
Scale (n) 95% CI 95% CI
Item and Dimension (D) 1 2 3 n M Lower–Upper SD Lower–Upper
P09. Do you think teachers know the consequences that
coexistence with non-vaccinated children could have on
students and their person?
791 174 35 1000 1.24 1.21–1.28 0.50 0.47–0.54
P10. Do administrations have measures to ensure the
health of pregnant teachers? 828 149 23 1000 1.20 1.17–1.22 0.45 0.41–0.48
P11. Do administrations have measures to ensure the
health of teachers with minor children or family
members with at-risk diseases?
840 143 17 1000 1.18 1.15–1.20 0.42 0.39–0.46
P12. Do parents of vaccinated students know the risk of
their children when living with other non-vaccinated
peers?
836 147 17 1000 1.18 1.16–1.21 0.43 0.39–0.46
D4 = Consequences and risks 1.20 1.18–1.23 0.41 0.37–0.44
Total 2.05 2.04–2.06 0.22 0.20–0.23
Source: own elaboration.
Table 4. Gender count of the participating sample for dimension D1.
GENDER
Man Woman
Dimension (D) Item 1 2 3 1 2 3 n
D1 = Awareness and regulation P01 8 66 232 18 108 568 1000
P02 5 55 246 9 77 608 1000
Source: own elaboration
Table 5. ANOVA for gender independent samples for dimension D1.
Dimension
(D) Item M Man SD 95% CI M Woman SD 95% CI p Eta2 Direction
D1 =
Awareness
and regulation
P01 2.73 2.68–2.79 0.50 0.44–0.55 2.79 2.76–2.83 0.47 0.42–0.51 0.06 0.00 W > M
P02 2.79 2.74–2.84 0.45 0.39–0.50 2.86 2.83–2.89 0.38 0.34–0.42 0.01 0.01 W > M
D1t 2.76 2.72–2.80 0.40 0.35–0.43 2.83 2.80–2.85 0.35 0.32–0.37 0.01 0.01 W > M
Source: own elaboration
Post-hoc tests suggest that the mean of women is above that of men in dimension
D1 = Awareness and regulation, with higher means and propensity towards YES, so women
could generally be inferred to have a higher awareness of vaccines than men.
Statistically significant differences appear in item P02 and dimension D1, although
the size of the effect measured in the ANOVA test per eta squared being less than 0.06 has
to be considered weak.
3.2. Age Incidence Analysis
In Table 6, the distribution of the sample by age group can be observed: E1 = Under
30, E2 = Between 30 and 44, E3 = Between 45 and 59, E4 = Greater than 60.
As can be seen in Table 6, the distribution of the sample by age group is uneven, the
percentages of the age groups E1 = Under 30 (36.3%), E2 = Between 30 and 44 (34.8%), and
E3 = Between 45 and 59 (26.76%) are similar, while the percentage of the group (E4) greater than
60 (2.2%) is of a lower order of magnitude.
To analyze whether there are differences according to the age group in the questionnaire, an ANOVA was performed for independent samples. The results are listed
in Table 7.
Vaccines 2021, 9, 813 9 of 15
Table 6. Count by age group of the participating sample for dimension D1.
AGE
E1 = −30 E2 = 30–44 E3 = 45–59 E4 = +60
Dimension (D) 1 2 3 1 2 3 1 2 3 1 2 3 n
D1 = Awareness and
regulation
P01 9 36 318 6 88 254 11 46 210 0 4 18 1000
P02 2 26 335 5 59 284 7 44 216 0 3 19 1000
Source: own elaboration.
Table 7. ANOVA for independent samples by age group (E1, E2) for dimension D1.
Item M E1 = −30 SD 95% CI M E2 = 30–44 SD 95% CI p Eta2 Direction
P01 2.85 2.81–2.89 0.42 0.35–0.49 2.71 2.66–2.76 0.49 0.44–0.53 0.00 0.02 E1 > E2. E3
P02 2.92 2.88–2.95 0.30 0.23–0.35 2.80 2.75–2.84 0.43 0.38–0.49 0.00 0.02 E1 > E2. E3
D1t 2.88 2.85–2.92 0.29 0.25–0.33 2.76 2.71–2.80 0.40 0.36–0.43 0.00 0.03 E1 > E2. E3
Item M E3 = 45–59 D 95% CI M E4 = +60 SD 95% CI p Eta2 Direction
P01 2.75 2.68–2.81 0.52 0.45–0.59 2.82 2.64–2.96 0.39 0.20–0.49 0.00 0.02 E1 > E2. E3
P02 2.78 2.72–2.84 0.47 0.40–0.54 2.86 2.70–3.00 0.35 0.00–0.47 0.00 0.02 E1 > E2. E3
D1t 2.76 2.71–2.81 0.39 0.35–0.43 2.84 2.71–2.95 0.28 0.15–0.38 0.00 0.03 E1 > E2. E3
Source: own elaboration.
Post hoc tests suggest that the mean age group under 30 is above the other age groups
in dimension D1 = Awareness and regulation, with higher means and, therefore, propensity
for YES, so it could be inferred that the age group under the age of 30, in general, has a
higher awareness of vaccines than the rest of the age groups.
Statistically significant differences appear in items P01, P02, and dimension D1, although, as the size of the effect measured in the ANOVA test per eta squared was less than
0.06, it has to be considered weak.
3.3. Analysis of the Impact of the Sector
In Table 8, the distribution of the sample by sector can be observed: S1 = Health,
S2 = Education, S3 = Economy.
Table 8. Count by sector of the participating sample for dimension D1.
SECTOR
S1 = Health S2 = Education S3 = Economy
Dimension (D) Item 1 2 3 1 2 3 1 2 3 n
D1 = Awareness and
regulation
P01 23 109 422 2 35 292 1 30 86 1000
P02 13 91 450 0 24 305 1 17 99 1000
Source: own elaboration
As can be seen in Table 8, the distribution of the sample by sector is uneven; the
percentage of the health sector (55.4%) is more than half of the sample, while the percentage
of the education sector (32.9%) is one-third of the sample, and the share of the economy
sector (11.7%) is a minority.
To analyze whether there are differences according to the sector in the questionnaire,
an ANOVA was performed for independent samples. The results are listed in Table 9.
Vaccines 2021, 9, 813 10 of 15
Table 9. ANOVA for independent samples by sector for dimension D1.
Item M S1 = Health SD 95% CI p Eta2 Direction
P01 2.72 2.67–2.76 0.53 0.49–0.58 0.00 0.02 S2 > S1.S3
P02 2.79 2.75–2.83 0.46 0.41–0.51 0.00 0.02 S2 > S1
D1t 2.75 2.72–2.79 0.40 0.37–0.43 0.00 0.04 S2 > S1.S3
Item M S2 = Education SD 95% CI p Eta2 Direction
P01 2.88 2.84–2.92 0.34 0.28–0.40 0.00 0.02 S2 > S1.S3
P02 2.93 2.90–2.96 0.26 0.21–0.30 0.00 0.02 S2 > S1
D1t 2.90 2.88–2.93 0.25 0.21–0.29 0.00 0.04 S2 > S1.S3
Item M S3 = Economy SD 95% CI p Eta2 Direction
P01 2.73 2.64–2.81 0.47 0.40–0.53 0.00 0.02 S2 > S1.S3
P02 2.84 2.76–2.90 0.39 0.30–0.47 0.00 0.02 S2 > S1
D1t 2.78 2.71–2.85 0.37 0.32–0.41 0.00 0.04 S2 > S1.S3
Source: own elaboration.
Post hoc evidence suggests that the mean education sector is above the health sector
in dimension D1 = Awareness and regulation, with higher means and, therefore, with
propensity towards YES, so it could be inferred that the education sector generally has
a higher awareness of vaccines than the health sector, which has a more negative view.
The means of the economy sector are in an intermediate position, presenting significant
differences with the health sector and not significant with the education sector.
Statistically significant differences appear in items P01, P02, and dimension D1, although the size of the effect measured in the ANOVA test per eta squared when less than
0.06 has to be considered weak.
3.4. Impact Analysis by Human Development Index (HDI)
In Table 10, the distribution of the sample by Human Development Index (HDI) can
be observed: I1 = Very High, I2 = High, I3 = Medium, I4 = Low.
Table 10. Count by Human Development Index (HDI) for dimension D1.
IDH
I1 = Very
High I2 = High I3 = Medium I4 = Low
Dimension (D) 1 2 3 1 2 3 1 2 3 1 2 3 n
D1 = Awareness
and regulation
P01 11 135 727 12 31 42 1 6 24 2 2 7 1000
P02 8 97 768 2 30 53 3 2 26 1 3 7 1000
Source: own elaboration.
As can be seen in Table 10, the sample distribution by Human Development Index
(HDI) is uneven; the percentage of the group I1 = Very high (87.3%) is of an order of
magnitude greater than the percentage of groups I2 = High (8.5%), I3 = Medium (3.1%), and
I4 = Low (1.1%) that are of the same order of magnitude.
To analyze whether there are differences according to the Human Development Index
(HDI) in the questionnaire, an ANOVA was conducted for independent samples. The
results are listed in Table 11.
The post hoc tests suggest that the mean of the HDI group: I1 = Very high is above the
other groups in dimension D1 = Awareness and regulation, with higher means and, therefore,
with propensity towards YES, so it could be inferred that the HDI group: I1 = Very high, in
general, has a higher awareness of vaccines than the rest of the groups.
Statistically significant differences appear in items P01, P02, and dimension D1, although the size of the effect measured in the ANOVA test per eta squared being less than
0.06 has to be considered weak in item P02, while item P01 and dimension D1, being eta
squared above 0.06, can be considered with a mean effect.
Vaccines 2021, 9, 813 11 of 15
Table 11. ANOVA for independent samples by Human Development Index (HDI) for dimension D1.
Item M I1 = Very high SD 95% CI M I2 = High SD 95% CI p Eta2 Direction
P01 2.82 2.79–2.85 0.42 0.38–0.45 2.35 2.20–2.50 0.72 0.63–0.79 0.00 0.08 I1 > I3 > I4 > I2
P02 2.87 2.85–2.89 0.36 0.33–0.40 2.60 2.49–2.71 0.54 0.47–0.61 0.00 0.04 I1 > I3 > I2 > I4
D1t 2.85 2.82–2.87 0.33 0.30–0.35 2.48 2.38–2.57 0.47 0.43–0.50 0.00 0.09 I1 > I3 > I4 > I2
Item M I3 = Medium SD 95% CI M I4 = Low SD 95% CI p Eta2 Direction
P01 2.74 2.55−2.92 0.51 0.28–0.68 2.45 2.00–2.89 0.82 0.33–1.00 0.00 0.08 I1 > I3 > I4 > I2
P02 2.74 2.50–2.94 0.63 0.24–0.84 2.55 2.10–2.89 0.69 0.33–0.93 0.00 0.04 I1 > I3 > I2 > I4
D1t 2.74 2.57–2.89 0.44 0.28–0.55 2.50 2.23–2.75 0.45 0.26–0.52 0.00 0.09 I1 > I3 > I4 > I2
Source: own elaboration.
3.5. Analysis of Incidence by Continent
Table 12 shows the distribution of the sample by continent: C1 = Europe, C2 = America,
C3 = Asia, C4 = Africa, C5 = Oceania.
Table 12. Count by continent of the participating sample for dimension D1.
CONTINENT
C1 = Europe C2 = America C3 = Asia C4 = Africa C5 = Oceania
Dimension (D) 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 n
D1 = Awareness
and regulation
P01 12 122 696 3 38 52 8 7 25 3 7 25 0 0 2 1000
P02 5 88 737 3 31 59 1 6 33 5 7 23 0 0 2 1000
Source: own elaboration.
As can be seen in Table 12, the distribution of the sample by continent is uneven; the
percentage C1 = Europe (83%) is of an order of magnitude greater than the percentage of the
other continents C2 = America (9.3%), C3 = Asia (4%), C4 = Africa (3.5%), and C5 = Oceania
(2%), which are of the same order of magnitude.
To analyze whether differences exist according to the continent in the questionnaire, an
ANOVA was performed for independent samples, excluding Oceania analysis, as only two
participants from that continent completed the questionnaire, which makes it unsuitable
for statistical analysis using resampling techniques through the Monte Carlo simulation
method using the bootstrap algorithm. The results are listed in Table 13.
Table 13. ANOVA for independent samples by continent for dimension D1.
Item M C1 = Europe SD 95% CI M C2 =
America SD 95% CI p Eta2 Direction
P01 2.82 2.80–2.85 0.42 0.38–0.45 2.53 2.41–2.64 0.56 0.49–0.63 0.00 0.06 C1 > C2. C3
P02 2.88 2.86–2.90 0.34 0.30–0.38 2.60 2.49–2.71 0.55 0.47–0.63 0.00 0.06 C1 > C2
D1t 2.85 2.83–2.87 0.32 0.29–0.34 2.56 2.47–2.66 0.47 0.43–0.51 0.00 0.08 C1 > C2. C3.
C4
Item M C3 = Asia SD 95% CI M C4 = Africa SD 95% CI p Eta2 Direction
P01 2.82 2.80–2.85 0.42 0.38–0.45 2.53 2.41–2.64 0.56 0.49–0.63 0.00 0.06 C1 > C2. C3
P02 2.88 2.86–2.90 0.34 0.30–0.38 2.60 2.49–2.71 0.55 0.47–0.63 0.00 0.06 C1 > C2
D1t 2.85 2.83–2.87 0.32 0.29–0.34 2.56 2.47–2.66 0.47 0.43–0.51 0.00 0.08 C1 > C2. C3.
C4
Source: own elaboration.
In items P01, P02, and dimension D1, the mean of respondents from the continent
C1 = Europe is above the rest of the continents in dimension D1 = Awareness and regulation,
with higher means and, therefore, with propensity towards YES, so it could be inferred that
respondents from the continent C1 = Europe generally have a higher awareness of vaccines
than respondents from other continents.
Vaccines 2021, 9, 813 12 of 15
Statistically significant differences appear in items P01, P02, and dimension D1, although the size of the effect measured in the ANOVA test per eta squared being less than
0.06 has to be considered weak in item P01, whereas, item P02, being eta squared above
0.06, can be considered with a mean effect.
4. Discussion and Conclusions
Research on the importance of vaccines in health is very broad, so the conclusions
offered in this article are only a part of this. However, the results reflect a very interesting
picture of the problem of vaccination from the world’s vaccine awareness and regulation
dimension (D1) in a period closely linked to the start of the COVID-19 pandemic, since the
completion of the work was in March 2020.
It is important to note that 100% of respondents of all ages, sex, profession, human
development index, and continent positively value vaccines as basic tools to ensure the
health of citizens and, above all, to prevent possible contagions, stressing that, since
vaccines, infant mortality has fallen considerably, and only in cases where vaccines are
not yet available is there significant mortality, especially in developing countries. In this
regard, it should be recalled that Article 35 of the Charter of Fundamental Rights of the
European Union [35] provides that everyone has the right to health prevention and to
benefit from the corresponding medical care in accordance with the conditions laid down
in national provisions. Moreover, it is essential to protect the lives of infants, making it
totally incomprehensible not to do so against diseases that can be avoided with vaccines.
Society’s awareness of the importance of vaccines and their relevant regulation by
administrations has been an issue whose visibility in the media and social media has
been increasing in the last decade, mainly due to their effectiveness and immersion of
immunization around the world. However, they have also influenced vaccine movements
with their constant public positioning against vaccination. Indeed, reluctance to vaccinate
all countries is concerned not only with low-income countries, but has become a problem affecting everyone. That is why WHO [20] has repeatedly expressed concern at the
expansion of anti-vaccine speakers, covering not only certain rural minorities, but even
expanding in urban areas with high purchasing power, and in all social classes [36]. There
is no doubt that raising awareness of the importance of vaccination is a key challenge
that all international agencies must address in order to ensure human rights and peaceful
coexistence in inclusive societies.
In the research carried out, it has been shown from a gender perspective that the mean
of women makes a higher assessment than men in considering that society is aware of
the importance of vaccines (D1, P1). However, there are no significant gender differences
in whether administrations have regulated actions for vaccine compliance (D1, P2). This
outcome could be affected by mothers who are mostly responsible for their sons’ and
daughters’ vaccination schedule, so they could have a more up-to-date attitude, training,
and information.
The group of people under the age of 30 is significantly different from the other age
groups in their positive assessment of the awareness of society (D1, P1). In addition, higher
scores are also evident in the group of people under 30 years of age, although of lower
value, on whether administrations have regulated actions for the compliance of vaccination
(D1, P2). There is no doubt that progress in vaccination over the past three decades has
been very significant, not only because of technological advances, but also because of the
increased incidence of vaccines, transparency, and safety.
Three main sectors have been considered: health, education, and economics, with
the aim of studying whether there were differences on the subject of research. The mean
of education sector has been shown to be significantly higher than that of the health
sector, with the economy sector in an intermediate position. In this regard, other work
shows that, in some areas, education contributes to greater acceptance and recognition of
vaccination [37]. However, it was shocking to researchers that the health sector was the
least valued at raising society’s awareness of the importance of vaccination and regulating
Vaccines 2021, 9, 813 13 of 15
administrations’ actions for vaccine compliance, so research would need to be done on the
reasons for this assessment and its possible impact to improve social awareness campaigns.
In relation to the Human Development Index (HDI), it has been shown that the mean
HDI = very high group is higher than that of the HDI = medium and low groups, offering
results that are totally consistent with studies done by WHO.
It is the continent C1 = Europe in which we find significantly higher means compared
to other continents (C2 = America; C3 = Asia; C4 = Africa; and C5 = Oceania).
In conclusion, it can be indicated that the profiles of women, people under 30 years of
age, the education sector, high human development index, and the European continent are
those that most values society’s awareness of the importance of vaccination (D1, P1) and
the regulation of actions for the implementation of vaccination (D1, P2). It is a very hopeful
conclusion to advance the construction of inclusive societies, creating greater involvement
of society as a whole through effective and evidence-based communication to allay fears,
address concerns, and promote acceptance of vaccination around the world. It should,
therefore, be remembered that people who delay or reject vaccination for themselves or
their children pose a growing challenge for countries seeking to close immunization gaps.
According to WHO [12], one in five children worldwide do not yet receive regular vital
immunizations, and around 1.5 million children die each year from diseases that could be
prevented with vaccines that already exist.
The responsible awareness and active involvement of society worldwide about the
importance of vaccination is critical to advancing the construction of a better world with
safe planning and regulation that ensures compliance. Significantly, international agencies
must be vigilant in order to deal with any incidents that may occur. Indeed, as has been
shown in 2020, as a result of the COVID-19 pandemic, more than 14 million infants did not
receive an initial dose of the DTP vaccine (diphtheria, tetanus and pertussis), demonstrating
inadequate access to health and immunization services, and more than 5.7 million are
only partially vaccinated. Similarly, more than 60% of these 19.7 million children live in
10 countries: Angola, Brazil, Ethiopia, the Philippines, India, Indonesia, Mexico, Nigeria,
Pakistan, and the Democratic Republic of the Congo. In addition, non-vaccination is
causing diseases that were considered eradicated, such as measles, to emerge, with new
outbreaks active in the United States and in several countries in Europe (Portugal, Italy,
Romania, etc.). It is clear that society’s awareness and proper regulation by administrations
around the world will achieve collective immunity through safe and effective vaccines and
make diseases rarer and, therefore, save lives.
In short, the research has highlighted the need for society to become aware of the
importance of vaccination, so that clear, truthful, and relevant information that transcends
safety in citizens about vaccination should be conveyed. In addition, they must report that
infectious diseases are a major cause of morbidity and mortality across the globe, mainly in
older people and those with chronic diseases. Consequently, effective and evidence-based
communication is key to allaying fears, addressing concerns, and promoting acceptance of
vaccination around the world. Reasonably, adequately raising awareness of the importance
of vaccines will lead to the building of inclusive societies in which all citizens enjoy the
health benefit, ensuring compliance with SDG3, “Ensuring healthy living and promoting
well-being for all at all agesâ€, without discrimination of any kind.
Author Contributions: Conceptualization, E.G.-T. and A.P.-R.; methodology, A.C.-M., A.P.-R. and
E.L.-P.; software, A.C.-M. and E.L.-P.; validation, A.C.-M., E.G.-T. and A.P.-R.; formal analysis,
A.C.-M.; investigation, E.G.-T. and A.P.-R.; resources, E.L.-P. and A.C.-M.; data curation, E.L.-P.
and A.C.-M.; writing—original draft preparation, E.G.-T. and A.P.-R.; writing—review and editing,
A.P.-R., E.G.-T. and A.C.-M.; visualization, E.L.-P., A.P.-R. and A.C.-M.; supervision, A.P.-R. and
E.G.-T.; project administration, A.P.-R.; funding acquisition, A.P.-R. All authors have read and agreed
to the published version of the manuscript.
Funding: This research has received assistance from the Scientific Research and Technology Transfer
Project (SBPLY/000149) funded by the Ministry of Education, Culture and Sports of Castilla-La
Mancha and European Regional Development Funds (ERDF).
Vaccines 2021, 9, 813 14 of 15
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Due to the anonymity and confidentiality of the data obtained, the authors have not reported any of the data obtained, the purpose of which is exclusively the development
of this research.
Acknowledgments: The authors would like to thank the financial organizations and participants for
their voluntary and supportive participation in this research.
Conflicts of Interest: The authors declare that they have no conflicts of interest.
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We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.
Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.
There is a very low likelihood that you won’t like the paper.
Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.
We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.
You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.
We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.
You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
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Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Read moreEach paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Read moreThanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.
Read moreYour email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.
Read moreBy sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.
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