The purpose of this study was to define and measure several component parts of parents' decision-making process about the recommended vaccinations for children. After identifying the various components, the intent was to determine if some background variables, specific factors influencing the decision-making process (e.g., social status and sources of information about vaccinations), and parents' perceived vaccinations effectiveness were useful in predicting whether parents were likely to have their children vaccinated. A sample of Sicilian parents was chosen because, among all the Italian regions, Sicily has one of the highest coverage rates of recommended immunisation.
Several interesting findings were revealed. First of all, the percentage of parents' positive attitudes towards vaccinations was exceptionally high compared with other similar studies [7
]. This finding could be linked to the fact that in our study parents showed very good knowledge about the side effects of vaccines and, subsequently, deep awareness of their safety. The explanation for reports of great knowledge and deep awareness could be the trust the parents had in their FP (prior to the survey 74.4% received information from the FP and 97.6% submitted their children to the recommended vaccinations). Secondly, prior to the survey, the vast majority of children (97.6%) were vaccinated according to the national recommended vaccination scheme. This data could be noteworthy because in Italy children can be enrolled in a preschool even if not vaccinated for recommended vaccines.
These data probably could be useful to demonstrate that FP offers a unique surveillance opportunity. In fact, every child in Italy is registered free of charge with a FP from birth until 14 years of age within the NHS. Thus, each FP has a precise paediatric population under his care (800-1000 children) and his public duty includes routine control visits that are perfect opportunities for vaccination offer, disease control and surveillance. Moreover, these findings confirm the results from other studies which indicated that the most frequent factor influencing parents' decision about childhood vaccinations was advice from doctors [10
Another interesting finding is related to the evaluation of predictive factors useful in explaining possible negative attitudes towards recommended vaccinations. Differently from other similar studies [5
], our findings showed a lack of correlation among the decision to have their children vaccinated and factors traditionally considered important in influencing the parents' decision making process: parents' socio-demographic characteristics (education level, age and sex), presence of other children in the nuclear family, possible influence of press, mass or web media.
Nevertheless, potential biases should be considered before generalizing these results to all parents of Italian young children. The most important possible bias is that the parents who agreed to participate in the study may be those who were most in favour of vaccinations and therefore the most inclined to vaccinate their children with recommended vaccinations. This bias is unavoidable and, although we are not able to provide information on refusals, we think that its influence would be the same in the rest of Italy.
One other bias could be linked to the fact that we do not really know whether children were vaccinated or not with recommended vaccines. In our opinion the effect of this potential bias would have been minimal because the parents completed a strictly anonymous self-administered questionnaire that they returned directly to the researchers in a prepared envelope to protect anonymity. Secondly, official data indicates that in Sicily recommended vaccination rates are more than 80.0% [1
Another limit of the study is also due to the fact that it did not collect information on religion and parents' level of income. It has been demonstrated that in many countries, due to the lack of official recommendation and of reimbursement, these variables have a strong influence on the acceptance of vaccines [5
]. Although this information would probably have been useful to better describe the response pattern, we do not believe that this fact influenced our results first of all because the Italian population is quite homogeneous from a religious point of view (in 2006, 95.8% of Italian people were Catholics), and secondly because, differently from other countries, in Italy economics is not a significant barrier to vaccinations because of the free access to health care and, subsequently, to the recommended vaccinations.
Despite potential biases and limits, our results suggest that modifiable determinants for a negative attitude to comply with recommended vaccinations could probably be based on a lack of specific knowledge. In fact, there is still uncertainty surrounding the safety of recommended vaccines. This barrier to vaccinations might be overcome firstly by improving health education of parents in the vaccination programs. Interventions should emphasise the benefits of combining antigens, such as less pain for the child and fewer vaccination visits. Parents may also need information about how recommended vaccines work in order to avoid misconceptions over safety.
Clearly, the NHS needs to do more in informing people about the process of immunisation in order to allay fears (e.g., information in the antenatal period may enable parents to make more informed decisions about recommended vaccinations). In fact, the majority of parents in the present study had information prior to their child's immunisation from their FP. Nevertheless, other sources of information were press or mass media, and websites. Thus, it is still important to ensure that parents have the information to make the informed decisions they desire.
The finding that parents would vaccinate their children even if it would be not required is encouraging because it could indicate a social responsibility. However, parental uncertainty about the need for recommended vaccines is a matter requiring attention. Thus, efforts to improve uptake by FP could focus on community benefits.
Finally, in Italy, parents of preschoolers generally receive an invitation to attend, with no information about the vaccines and the diseases they protect against. Further research by this team is underway to examine parental satisfaction with this and many other aspects of the childhood immunisation service.