Do social media epistemological beliefs and health perception impact parents’ vaccine hesitancy? A mediation analysis

Abstract

In recent years, there has been a notable increase in vaccine hesitancy among individuals. It is crucial to identify the factors contributing to vaccine hesitancy to effectively address this issue. This study aims to investigate the impact of social media-specific epistemological beliefs on vaccine hesitancy and the mediating role of health perception in this impact. This study is a cross-sectional study conducted with 444 parents. Data were collected using the Personal Information Form, the Social Media-Specific Epistemological Beliefs Scale, the Perception of Health Scale, and the Vaccine Hesitancy Scale. When there is no mediator variable, the total effect of social media-specific epistemological beliefs on vaccine hesitancy is statistically significant (β = −0.219, p < 0.001). However, it was found that health perception did not mediate the relationship between social media-specific epistemological beliefs and vaccine hesitancy (β = 0.0038, 95% confidence interval (−0.0090, 0.0205)). Furthermore, it was determined that social media-specific epistemological beliefs positively predicted health perception (β = 0.136, p < 0.01). Health perception was found to have no significant effect on vaccine hesitancy (β = 0.028, p > 0.05). It can be concluded that social media-specific epistemological beliefs negatively predict vaccine hesitancy, and this effect is independent of health perception. Primary healthcare professionals should consider incorporating interventions aimed at enhancing individuals’ social media-specific epistemological beliefs into their health education programs related to vaccines.

Introduction

Childhood vaccines are widely acknowledged as one of the major achievements in public health interventions due to their significant role in decreasing morbidity and mortality rates associated with vaccine-preventable diseases (1).

Despite the benefits of vaccines, there has been a recent increase in vaccine hesitancy, with more individuals expressing reluctance to get vaccinated. The World Health Organization Vaccine Hesitancy Working Group defines vaccine hesitancy as ‘a delay in acceptance or refusal of vaccines despite the availability of vaccination services’ (2). In a multinational study involving participants from countries such as Turkey, Italy, Pakistan, Iran and Bulgaria, the rate of vaccine hesitancy was determined to be 13.7% (3). Similarly, in a study conducted in Argentina, the rate was reported as 11.5% (4), and in a study carried out in Italy, it was found to be 15.6% (5). Research indicates that parents often turn to the Internet and social media for information on vaccines (3). However, it is noteworthy that websites, including social media platforms, frequently contain substantial volumes of negative and inaccurate information regarding vaccination (6). Therefore, it is essential for parents to critically evaluate the source and credibility of information on social media and other online platforms regarding vaccination.

At this point, the concept of epistemological beliefs becomes prominent. Epistemological beliefs encompass an individual’s acceptance of the nature, source, structure and accuracy of knowledge (7). It involves one’s personal acceptance of what constitutes knowledge, how it is acquired and transmitted, its boundaries and the criteria for its validity, forming their epistemological stance. Individuals hold conceptualizations and beliefs regarding the nature of knowledge which greatly influence how they interpret and understand information (8).

Vaccine hesitancy often stems from attitudes which can be influenced by self-perception (9). When an individual’s attitude toward a behavior is shaped through the self-perception process, their health perception may also play a role in influencing their attitudes. Health perception encompasses an individual’s assessment of their physical, mental and social well-being, including their personal beliefs and statements about their health status (10). This study aims to explore the impact of social media-specific epistemological beliefs on vaccine hesitancy and the mediating role of health perception in this impact.

Methods

Theoretical framework and research hypotheses

The mediating role of health perception in the impact of social media-specific epistemological beliefs on vaccine hesitancy

Health perception refers to an individual’s personal beliefs and statements regarding their health status, serving as a robust indicator of their physical, mental and social well-being. Moreover, it significantly influences individuals’ health-seeking behaviors and health responsibilities (10). The process of health promotion entails adopting healthy lifestyle behaviors. The adoption of a healthy lifestyle is closely linked to an individual’s health perceptions (11). Considering vaccination as one of the most effective measures for disease prevention and health promotion (12), the level of health perception may also impact vaccine hesitancy. Individuals with a strong health perception are more inclined to accept vaccination as a preventative measure for health (11). Therefore, enhancing health perception may decrease the likelihood of developing vaccine hesitancy. Furthermore, this heightened level of health perception may act as a deterrent against vaccine hesitancy arising from information obtained from social media. Therefore, in this context, health perception can function as a mediating factor in the relationship between information obtained from social media and vaccine hesitancy attitudes. Based on this conceptual framework, we propose the following hypotheses:

• H₁ = Social media-specific epistemological beliefs influence health perception.

• H₂ = Health perception influences vaccine hesitancy.

• H₄ = Health perception mediates the relationship between social media-specific epistemological beliefs and vaccine hesitancy.

The impact of social media-specific epistemological beliefs on vaccine hesitancy

Vaccination stands as one of the most strategic methods for intervening against common childhood infections. Childhood vaccinations have been associated with a decrease in vaccine-preventable infections and deaths among children (13). However, despite these beneficial effects of vaccinations, some parents may experience vaccine hesitancy due to mistrust in vaccines. Vaccine hesitancy can arise from various factors, including misinformation, distrust in healthcare institutions and professionals, and lack of knowledge (14). Social media plays a significant role in disseminating misinformation about vaccines and can contribute to the spread of vaccine hesitancy (15).

The advancement of mobile internet technology, along with the widespread use of mobile devices and the proliferation of social media applications, has facilitated the dissemination, creation, access and sharing of health information among users. However, this progress has also brought about certain challenges. One such challenge is the task of sifting through the vast and incessant stream of data on social media platforms to extract accurate and pertinent information. Additionally, concerns have arisen regarding the reliability, quality and accessibility of health-related content on these platforms. Many social media users lack expertise in health matters but possess a strong desire to seek answers. Consequently, this scenario has heightened the risk of users believing in misinformation or rumors when encountering unofficial and unregulated health information (16). However, the assessment of information quality is intricately linked to an individual’s epistemological beliefs.

Understanding epistemology aids in comprehending how individuals navigate conflicting information, evaluate novel knowledge and make pivotal decisions that impact their lives (17). Epistemological beliefs specific to social media focus on individuals’ beliefs about obtaining information from social media and encompass dimensions such as simplicity and certainty of social media-based knowledge, the source of knowledge, and justification for knowing (18). Additionally, social media-specific epistemological beliefs involve users questioning the information sources they encounter on social media platforms, considering the simplicity and accuracy of information, reasoning about information and checking other sources of information (19). Consequently, individuals with well-developed epistemological beliefs specific to social media are anticipated to recognize the potential for information on social media to evolve, exercise control over their information sources and engage in critical evaluation of the information presented. As a result, it is hypothesized that individuals with advanced social media-specific epistemological beliefs will adopt a critical stance towards vaccine-related information encountered on social media platforms, potentially reducing the likelihood of vaccine hesitancy. According to the conceptual framework outlined, we propose the following hypothesis:

• H₃ = Social media-specific epistemological beliefs influence vaccine hesitancy.

In line with these hypotheses, the model of the research is presented in Figure 1. In this model: ‘Direct effect’ refers to the impact of X on Y when all three variables are simultaneously incorporated into the model, with the mediating variable being held constant. ‘Total effect’ is the impact of X on Y in a model where there is no mediating variable. ‘Indirect effect’ represents the influence of X on Y mediated by a mediating variable (M) (20).

Table 1.

The comparison of scale scores based on personal characteristics.

				VH
		PH	SMEB	Lack of confidence subscale	Risks subscale	Total
	n/%	$\overline{{\rm X}}$ ± SD	$\overline{{\rm X}}$ ± SD	$\overline{{\rm X}}$ ± SD	$\overline{{\rm X}}$ ± SD	$\overline{{\rm X}}$ ± SD
Gender
Female	366/82.4	50.37 ± 7.69	56.39 ± 8.62	11.55 ± 5.58	8.61 ± 2.60	20.16 ± 7.26
Male	78/17.6	50.97 ± 7.88	53.60 ± 9.23	10.81 ± 5.54	7.96 ± 2.52	18.77 ± 7.28
t/p		−0.629/0.53	2.564/0.011	1.066/0.28	2.019/0.044	1.537/0.125
Education status
Primary school	79/17.8	46.11 c ± 7.05	54.30 b ± 8.12	11.13 ± 4.64	8.70 ± 2.41	19.82 ± 5.69
Secondary school	67/15.1	48.37 b ± 6.43	53.61 b ± 7.88	11.51 ± 5.95	8.19 ± 2.38	19.70 ± 7.39
High school	114/25.7	50.84 a ± 8.22	55.14 b ± 9.25	11.61 ± 6.01	8.57 ± 2.56	20.18 ± 7.58
University	184/41.4	52.89 a ± 7.12	57.90 a ± 8.72	11.39 ± 5.57	8.48 ± 2.76	19.87 ± 7.68
F/p		17.983/0.000	6.039/0.000	0.125/0.945	0.492/0.688	0.077/0.972
Getting all vaccinations for the child
Yes	419/94.4	50.37 ± 7.77	55.83 ± 8.87	11.05 ± 5.25	8.32 ± 2.49	19.37 ± 6.77
No	25/5.6	52.20 ± 6.81	57.12 ± 7.26	17.56 ± 7.24	11.52 ± 2.47	29.08 ± 9.15
t/p		−1.150/0.251	−0.713/0.476	−5.881/0.000	−6.253/0.000	−6.811/0.000
Experiencing a post-vaccination reaction in the child
Yes	55/12.4	50.25 ± 7.39	57.76 ± 6.83	12.64 ± 5.84	10.02 ± 2.71	22.65 ± 7.79
No	389/87.6	50.51 ± 7.77	55.64 ± 9	11.25 ± 5.53	8.28 ± 2.51	19.53 ± 7.12
t/p		−0.226/0.821	1.682/0.093	1.734/0.084	4.759/0.000	3.010/0.003
Having doubts while vaccinating the child
Yes	101/22.7	49.82 ± 7.59	55.75 ± 8.09	14.99 ± 6.16	10.26 ± 2.39	25.25 ± 7.41
No	343/77.3	50.67 ± 7.76	55.95 ± 8.99	10.37 ± 4.93	7.98 ± 2.42	18.35 ± 6.45
t/p		−0.968/0.334	−0.196/0.845	7.801/0.000	8.341/0.000	9.129/0.000
Being influenced by negative vaccine comments on social media
Yes	127/28.6	49.5 ± 7.81	54.82 ± 8.82	13.53 ± 5.92	9.69 ± 2.47	23.22 ± 7.44
No	317/71.4	50.86 ± 7.66	56.34 ± 8.75	10.57 ± 5.21	8.02 ± 2.49	18.59 ± 6.77
t/p		−1.682/0.093	−1.650/0.100	5.188/0.000	6.422/0.000	6.321/0.000
Believing in rumors of harmful substances in vaccines
Yes	113/25.5	49.37 ± 7.57	55.32 ± 9.18	14.65 ± 6.45	10.52 ± 2.38	25.18 ± 7.87
No	331/74.5	50.85 ± 7.74	56.1 ± 8.65	10.31 ± 4.78	7.81 ± 2.29	18.12 ± 6.10
t/p		−1.764/0.078	−0.819/0.413	7.586/0.000	10.796/0.000	9.820/0.000

a,b,c

Superscripts indicated by different letters show a significant difference between groups.

t: independent samples t test; F: one-way analysis of variance; SMEB: social media specific epistemological beliefs; PH: perception of health; VH: vaccine hesitancy X _

Parents who reported not administering all recommended vaccines for their child had higher VH total scores (t = −6.811; p < 0.001; Table 1), as well as higher scores in the lack of confidence subscale (t = −5.881; p < 0.001; Table 1) and risks subscale (t = −6.253; p < 0.001; Table 1). Additionally, parents whose children experienced post-vaccination reactions demonstrated higher VH total scores (t = 3.010; p = 0.003) and risks subscale scores (t = 4.759; p < 0.001; Table 1). Parents who expressed hesitancy toward vaccinating their child showed higher VH total scores (t = 9.129; p < 0.001; Table 1), lack of confidence subscale scores (t = 7.801; p < 0.001) and risks subscale scores (t = 8.341; p < 0.001; Table 1). Similarly, parents influenced by negative vaccine comments on social media had higher VH total scores (t = 6.321; p < 0.001; Table 1), lack of confidence subscale scores (t = 5.188; p < 0.001; Table 1) and risks subscale scores (t = 6.422; p < 0.001; Table 1). Lastly, parents who believed in rumors regarding harmful substances in vaccine content had higher VH total scores (t = 9.820; p < 0.001; Table 1), lack of confidence subscale scores (t = 7.586; p < 0.001; Table 1) and risks subscale scores (t = 10.796; p < 0.001; Table 1).

According to the CIs obtained using the bootstrap technique, it was determined that the indirect effect of SMEB on VH through PH is not significant, suggesting that PH does not mediate the relationship between SMEB and VH (β = 0.0038, 95% CI (−0.0090, 0.0205); Figure 2). However, it was found that SMEB positively predicts PH (β = 0.136, p < 0.01; Figure 2, Table 2). PH, in turn, was found to have no significant effect on VH (β = 0.028, p > 0.05; Figure 2, Table 2). When no mediator variable was involved, the total effect of SMEB on VH was statistically significant (β = −0.219, p < 0.001; Figure 2). Additionally, the direct effect was statistically significant (β = −0.223, p < 0.001; Figure 2, Table 2).

Figure 2.

The mediating role of perception of health in the impact of social media-specific epistemological beliefs on vaccine hesitancy (N = 444).

CI: confidence interval

[Figure omitted. See PDF]

Table 2.

Regression analysis results for the mediating role of PH in the impact of SMEB on VH (N = 444).

Outcome variables
	M (PH)			Y(VH)
Predictor variables		β	SE		β	SE
X (SMEB)	a	0.136**	0.041	c′	−0.223*	0.039
M (PH)	–			b	0.028***	0.044
Constant	iM	42.853*	2.337	iY	30.948	2.854
		R2 = 0.024			R2 = 0.070
		F = 10.899; p < 0.01			F = 16.765; p < 0.001

*

p < 0.001

**

p < 0.01

***

p > 0.05

SE: standard error; β: unstandardized beta coefficient; SMEB: social media-specific epistemological beliefs; PH: perception of health; VH: vaccine hesitancy

Discussion

The study results revealed that social media-specific epistemological beliefs positively predicted health perception. Moreover, it was observed that health perception did not influence vaccine hesitancy, and there was no mediating role of health perception in the relationship between social media-specific epistemological beliefs and vaccine hesitancy. Furthermore, social media-specific epistemological beliefs were identified as a negative predictor of vaccine hesitancy, with a significant direct impact on vaccine hesitancy.

In this study, female parents were found to exhibit more robust social media-specific epistemological beliefs than males. This discrepancy could potentially be attributed to the higher self-confidence and lower anxiety levels observed in males regarding online reading (29). Such differences in anxiety levels might prompt females to approach the information they read more critically, leading them to question its accuracy and thereby contributing to these beliefs.

The results of this study revealed that parents with a university and high school education exhibited higher levels of health perception, whereas those with a university education demonstrated higher levels of social media-specific epistemological beliefs compared with those with lower levels of education. It is noteworthy that individuals with higher education levels tend to possess better health literacy (30, 31). Health literacy refers to the ability to access, comprehend, assess and apply health-related information in daily life decisions concerning maintaining or improving the quality of life, preventing diseases and promoting and protecting health (32). The acquisition of health information through higher health literacy may have contributed to the formation of parents’ health perceptions. Health literacy involves a range of skills including reading, writing and critical thinking. Consequently, higher health literacy may foster behaviors such as critically evaluating information and verifying it through diverse sources, reflecting elevated epistemological beliefs.

Parents who reported their children experiencing post-vaccination reactions exhibited higher levels of vaccine hesitancy and risk perception compared with those who did not encounter such reactions. This finding suggests that these negative experiences may lead to parental concerns and foster a perception of vaccines as posing risks. A previous study found that mothers either expressed hesitancy or temporarily halted vaccination following a vaccine reaction (33). This finding underscores the importance of healthcare professionals in primary care vaccination services effectively educating parents about potential vaccine reactions.

Parents who reported being influenced by negative vaccine comments on social media and believing rumors about harmful substances in vaccines exhibited higher levels of vaccine hesitancy, as well as higher levels of the lack of confidence and risk perception, the sub-dimensions of vaccine hesitancy. It is plausible that either parents’ lack of confidence and risk perception regarding vaccines are driving these beliefs or exposure to such comments and pre-existing beliefs about vaccines contribute to increased vaccine hesitancy, lack of confidence, and risk perception. One of the most significant factors contributing to vaccine hesitancy is distrust in effectiveness, safety and the system providing vaccines (34,35).

Our results indicated that social media-specific epistemological beliefs served as a positive predictor of health perception, thereby supporting our first hypothesis. This suggests that social media-specific epistemological beliefs positively contribute to the development of health perception. Individuals with well-developed epistemological beliefs are inclined to adopt critical approaches when assessing the accuracy of the information they encounter, leading to behaviors such as seeking additional information or verifying the accuracy of information through alternative sources, thereby enhancing health literacy. Health literacy, in turn, can affect health perception. Previous research has shown a positive relationship between health literacy and health perception (36). Another study reported that health literacy influences health perception (13). Further research is needed to provide more conclusive insights into the relationship between social media-specific epistemological beliefs and health perception.

The findings of the study revealed that health perception did not have an effect on vaccine hesitancy, and the proposed mediating role of health perception in the relationship between social media-specific epistemological beliefs and vaccine hesitancy was not supported. Considering that improving and protecting health are complementary concepts, it was hypothesized that individuals with a high health perception would have a positive attitude towards vaccines, resulting in lower levels of vaccine hesitancy. Furthermore, it was hypothesized that health perception would mediate the impact of social media-specific epistemological beliefs on vaccine hesitancy. However, our results indicated that such an effect was not present. These findings suggest that the impact of social media-specific epistemological beliefs on vaccine hesitancy is not contingent upon health perception. Although the parents in the study exhibited health perceptions above the average, they may not necessarily associate vaccination with maintaining health. Moreover, parents may lack a clear understanding of how vaccines contribute to disease prevention and the maintenance of health. These factors could have contributed to the observed outcome. However, no previous studies have explored such a mediating effect. To gain a better understanding and elucidate why health perception does not influence vaccine hesitancy, further scientific research is needed in this area.

Based on the findings of this study, social media-specific epistemological beliefs emerge as a negative predictor of vaccine hesitancy, and their direct impact on vaccine hesitancy is statistically significant. Thus, our third hypothesis has been confirmed. It is anticipated that individuals with well-developed social media-specific epistemological beliefs will exhibit a tendency to critically assess the information they encountered on social media platforms and validate it from other reliable sources (37). Considering vaccine hesitancy, it can be inferred that these individuals may be less likely to experience vaccine hesitancy. The results of this study support this inference.

Limitations and strengths

This study is subject to several limitations. First, the use of a non-probabilistic sampling method introduces potential biases, limiting the generalizability of the findings. Additionally, the scope of the study is confined to exploring the relationship between vaccine hesitancy, social media-specific epistemological beliefs and health perception solely in the context of childhood vaccinations. The findings cannot be generalized to vaccine hesitancy regarding vaccinations administered during adulthood.

A notable strength of this study lies in its novelty. It represents the first attempt in the literature to investigate the relationship between social media-specific epistemological beliefs, health perception and vaccine hesitancy. This pioneering effort contributes valuable insights to the existing body of knowledge on this subject matter.

Conclusion

The results suggest that social media-specific epistemological beliefs serve as a negative predictor of vaccine hesitancy and a positive predictor of health perception. However, health perception does not significantly affect vaccine hesitancy, and there is no mediating role of health perception in the relationship between social media-specific epistemological beliefs and vaccine hesitancy. In light of these findings, it appears that individuals with well-developed social media-specific epistemological beliefs are more inclined to critically evaluate negative vaccine-related information on social media, less prone to believing such information and more likely to question its accuracy, which reduces their propensity for vaccine hesitancy. Furthermore, the impact of social media-specific epistemological beliefs on vaccine hesitancy does not appear to be dependent on health perception.

Health education plays a pivotal role in public health initiatives. The results of this study can inform health education efforts aimed at mitigating vaccine hesitancy. Healthcare professionals working in primary care settings should prioritize empowering individuals through health education regarding vaccine hesitancy. This education should equip individuals with the skills to verify the accuracy of the information encountered on social media, encourage consultation of reliable sources and foster critical evaluation of information disseminated on social media. Additionally, health education materials should consistently incorporate strategies for verifying the accuracy of information on social media and provide guidance on accessing reliable sources of vaccine-related information.

Declaration of conflicting interests

The authors have no conflicts of interest to declare.

Ethical approval

The researchers obtained ethical approval from the university’s ethics committee (Date/Number: 2023/86), and informed consent was obtained from the parents.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Cahide Çevik https://orcid.org/0000-0002-9924-4536