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Çocukluk Aşılarının Uygulanmasını Reddeden Ebeveynlerin Tutumlarının Niteliksel Yöntemle İncelenmesi

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Çocukluk Aşılarının Uygulanmasını Reddeden Ebeveynlerin Tutumlarının Niteliksel Yöntemle İncelenmesi T.C. İSTANBUL ÜNİVERSİTESİ İSTANBUL TIP FAKÜLTESİ HALK SAĞLIĞI ANABİLİM DALI Çocukluk Aşılarının Uygulanmasını Reddeden Ebeveynlerin Tutumlarının Niteliksel Yöntemle İncelenmesi (Uzmanlık Tezi) Dr. Ahmet ABBASOĞLU Tez Danışmanı Prof. Dr. Günay GÜNGÖR İSTANBUL 2018 T.C. İSTANBUL ÜNİVERSİTESİ İSTANBUL TIP FAKÜLTESİ HALK SAĞLIĞI ANABİLİM DALI Çocukluk Aşılarının Uygulanmasını Reddeden Ebeveynlerin Tutumlarının Niteliksel Yöntemle İncelenmesi (Uzmanlık Tezi) Dr. Ahmet ABBASOĞLU Tez Danışmanı Prof. Dr. Günay GÜNGÖR İSTANBUL 2018 I ÖNSÖZ Bu tez, hazırlık, uygulama ve analiz olmak üzere her aşaması yoğun emek gerektirmiş, iki senelik bir çalışmanın ürünüdür. Bu çalışma, gönüllülerin çocuklarının aşılanması etrafındaki görüşlerini tespit etmesinin yanı sıra toplumun endişeleri olan bir bölümüyle samimi bir iletişim kurma çabasıdır. Bu esnada çok sayıda kişi hem bu çalışmaya destek vermiş hem de eğitim sürecime katkıda bulunmuştur. Çalışmaya hazırlık aşamasında beni teşvik ve bana yardım eden Marmara Üniversitesi Halk Sağlığı Anabilim Dalı’ndan Prof. Dr. Pınar Ay’a, görüşme formunun oluşturulması ve verilerin analizi aşamasında deneyimine ve bilgisine defalarca başvurduğum ve kadın ve üreme sağlığını öğreten Prof. Dr. Nuray Özgülnar’a, tez çalışmam sırasında rahatlıkla çalışmamı sağlayan, desteğini esirgemeyen Halk Sağlığı Anabilim Dalı Başkanı Prof. Dr. Ayşe Emel Önal’a, nitel araştırmayı sevdiren ve yapmaya teşvik eden, sağlığın sosyal boyutunu öğreten Prof. Dr. Selma Karabey’e, halk sağlığına başladığımda halk sağlığıyla ilgili ilk temel bilgileri aldığım Prof. Dr. Nurhan İnce’ye, istatistiği öğreten, güler yüzünü eksik etmeyen Prof. Dr. Halim İşsever’e, sağlık coğrafyası gibi önemli bir dalı bize tanıtan nazik hocam Prof. Dr. Bilge Hapçıoğlu’na, bölümde düzeni sağlamak için sorumluluğu alan, değerli alışkanlıklar kazandıran Prof. Dr. Bedia Ayhan’a, uzmanlık eğitimim ve tez çalışmam süresince bana yön veren, önüme çıkan her türlü zorlukta rahatlıkla ulaşabileceğim ve danışabileceğim; benim çalışmanın zor zamanlarında doğru rotada kalmamı sağlayan, kritik her anda deneyimlerini, sabrını, güler yüzünü ve desteğini esirgemeyen çok kıymetli danışman hocam Prof. Dr. Günay Güngör’e, Tez çalışmamın uygulama sırasında desteklerini esirgemeyen kıymetli, yardımsever meslektaşlarım Dr. Selahattin Avcı, Dr. Kaya Sami Nizamoğlu, Dr. Çiğdem Kılıçtaş, Dr. Buğra Taygun, Dr. Özden Yülek’e, Konuşmaların metin haline gelmesinde çalışan annem Gülden Abbasoğlu’na, referansların yazılmasında emeği geçen kardeşim Dr. Dt. Zerrin Abbasoğlu’na, çalışmanın hazırlık aşamasında konuyu her yönüyle tartışan oda arkadaşım Dr. İlke Karadağlı’ya, bölümdeki görevlerimizin çalışmanın takvimiyle uyumlu olmasını sağlayan asistan temsilcimiz Dr. Elif Ezirmik’e, aynı çalışma ortamını paylaştığım sohbetleriyle çalışmanın zorluklarını hafifleten Dr. Evin Aydın, Dr. Mehmet Kaya, Dr. Evren Tarım ve Dr. Ayla Güven’e, yardımsever Dr. Alparslan Duman ve Dr. Ayşe Demirel’e, karmaşık bürokratik işlerin pürüzsüz yürümesini sağlayan sekreterimiz Yusuf Yüceyaltırık ve herhangi bir II sıkıntıda bize nazikçe yardım eden Gözde Öztan’a, güler yüzlü personelimiz Ali Aydın’a, çalışma sırasınca manevi desteğini esirgemeyen ve gönüllülerle olan görüşmelerde bana eşlik ederek çalışmayı kolaylaştıran, değerli Dr. Çiğdem Aslaner’e, Bana insanları anlamayı öğreten annem, bilim ve tarihi öğreten babama ve cesareti öğreten kardeşime, Çalışmanın öznesi olan, gerçekleşmesini sağlayan, samimiyetleri ve sözleriyle katkıda bulunan, çok kıymetli gönüllü anne ve babalara, En içten teşekkürlerimi sunarım. Dr. Ahmet Abbasoğlu III İÇİNDEKİLER ÖNSÖZ…………………………………………………………………………………………I İÇİNDEKİLER……………………………………………………………………………….III RESİM, ŞEKİL VE TABLOLAR …………………………………………………………….X KISALTMALAR ………………………………………………………………………….…XI I. ÖZET ………………………………………………………………………………………..1 II. ABSTRACT ………………………………………………………………………………..3 III. GİRİŞ……………………………………………………………………………………....5 IV. GENEL BİLGİLER ……………………………………………………………………….7 A. EPİDEMİYOLOJİK DÖNÜŞÜM ………………………………………………...…7 B. AŞILARIN ÜRETİM TEKNİKLERİ ………………………………………………..8 1. Variyolasyon ve İlk Bilimsel Aşı ………………………………………………….8 2. Mikrop Teorisi ve İlk Modern Aşılar ……………………………………………...8 3. Oral Çocuk Felci, Kızamık, Kızamıkçık, Kabakulak ve Suçiçeği Aşıları ………...9 4. Kapsüler Polisakkarit, Protein Bazlı Ve Genetik Mühendisliğiyle Elde Edilmiş Aşılar …………………………………………………………………………………………10 a. Kapsüler Polisakkarit Aşılar …………………………………………….…10 b. Protein Bazlı Aşılar ………………………………………………………..10 c. Genetik Mühendisliği ve İlerisi …………………………………………....10 C. HALK SAĞLIĞI GİRİŞİMLERİ VE HALK SAĞLIĞINA ETKİSİ ……………...11 1. Çocuk Felci Aşısı ve Sürü Bağışıklığı…………………………………………..11 2. Genişletilmiş Bağışıklık Programı ……………………………………………...12 3. Kızamık ………………………………………………………………………....12 4. Kabakulak ………………………………………………………………………13 5. Aşı Reddinin Sonucu: Eski Hastalıkların Geri Gelişi ………………………..…14 IV 6. Türkiye’de Aşıyla İlgili Halk Sağlığı Girişimleri ……………………………....14 7. Türkiye’de Aşılama Programının Oluşması…………………………………….15 D. AŞILARIN GÜVENLİĞİNİN SAĞLANMASI……………………………………16 1. Aşıların İçerikleri ……………………………………………………………….16 2. Prezervatifler ……………………………………………………………………16 3. Thiomersalle İlgili EPA Rehber Kararları ……………………………………...17 4. Alerjiler ve Thiomersal …………………………………………………………18 5. Otizm ve Thiomersal ……………………………………………………………18 6. Aşıların Otizm Yaptığına Dair Sunulan Çalışmalar Ve Çürütülmeleri ………...18 7. Otizm Bağlantısının Araştırılması Ve Bulgu Bulunamaması …………………..20 8. Adjuvanlar ………………………………………………………………………20 9. Aditifler………………………………………………………………………….21 a. Jelatine Hipersensitivite…………………………………………………….21 b. İnsan Serum Albümininde Bulaşıcı Ajan Şüphesi ………………………...21 c. vCJD Riski …………………………………………………………………21 10. Üretim Rezidüleri ………………………………………………………………21 a. İnaktivasyon Ajanları ………………………………………………………21 b. Antibiyotikler ……………………………………………………………...22 c. Hücresel Rezidüler …………………………………………………………22 E. AŞI KARŞITLIĞI VE AŞI KARARSIZLIĞI ……………………………………...22 1. Aşı Karşıtlığının İlk Dönemleri ………………………………………………...22 2. Modern Aşı Karşıtlığı ………………………………………………………….23 3. ABD’de Thiomersal’in Aşılardan Çıkarılmasının Etkisi ………………………23 4. Wakefield’ın Çalışmasının Yarattığı Etki ……………………………………...24 V 5. Aşı Güvenliği Konusu Nasıl Ele Alınmalı ……………………………………..25 6. İnternette Aşı Reddi ……………………………………………………………25 7. Coğrafi Kümelenme ……………………………………………………………26 8. Aşı Kararsızlığı ………………………………………………………………...26 9. Aşı Kararsızlığı ile İlgili Yapılan Çalışmalar ………………………………….26 10. Türkiye’de Yapılan Çalışmalar ……………………………………………….30 11. Kazançlar ……………………………………………………………………..31 V. GEREÇ VE YÖNTEM …………………………………………………………………...32 A. ARAŞTIRMANIN TİPİ ……………………………………………………………32 B. ARAŞTIRMANIN YERİ VE ZAMANI …………………………………………...32 C. ARAŞTIRMANIN EVRENİ VE ÖRNEKLEMİ …………………………………..32 D. VERİ TOPLAMA ARACI VE YÖNTEMİ ………………………………………..32 E. VERİLERİN ANALİZİ …………………………………………………………….33 F. ARAŞTIRMA ETİĞİ VE İZİNLERİ ………………………………………………33 G. ARAŞTIRMADA KARŞILAŞILAN GÜÇLÜKLER VE KISITLILIKLAR ……..34 H. ARAŞTIRMANIN BÜTÇESİ ……………………………………………………..34 VI. BULGULAR …………………………………………………………………………….35 A. DEMOGRAFİK DAĞILIM ……………………………………………………….35 B. DERİNLEMESİNE GÖRÜŞMELERE AİT NİTEL BULGULARA GİRİŞ ……..39 C. AŞILARLA İLGİLİ ALGILARA DAİR NİTEL BULGULAR …………………..43 1. Aşıların Etkinliğiyle İlgili Algılar ……………………………………………43 a. Etkisiz ……………………………………………………………………...43 b. Şarta Bağlı Etki …………………………………………………………….45 c. Etkili ……………………………………………………………………….46 VI 2. Aşıların Güvenliğiyle İlgili Algılar …………………………………………..47 a. Bağışıklığın Baskılanması …………………………………………………47 b. Davranış ve Somatik Etkiler ……………………………………………….48 c. İdiopatik Kronik Hastalıklar ……………………………………………….52 d. Tedavisiz Oluşu ……………………………………………………………57 e. Tetikleyici Olay ……………………………………………………………57 f. Uzun Dönemli Bilinmeyen Etkiler …………………………………………60 g. Yabancı Maddelerle İlgili Endişeler ……………………………………….61 (1). Ağır Metaller ………………………………………………………62 (2). Adjuvan …………………………………………………………...65 (3). Canlı Aşı ………………………………………………………….66 (4). Hayvan Ürünü …………………………………………………….66 3. Aşıların Uygulama Yöntemiyle İlgili Algılar ………………………………...67 a. Sabit Değişmeyen Takvim …………………………………………………67 b. Erken Zaman ………………………………………………………………70 c. Yapılan Aşıların Çokluğu ………………………………………………….71 d. Takvimle İlgili Diğer Endişeler ……………………………………………73 D. BULAŞICI HASTALIKLARLA İLGİLİ ALGILARA DAİR NİTEL BULGULAR …………………………………………………………………………………74 1. Bulaşıcılık Riskiyle İlgili Algılar …………………………………………….74 a. Risk Düşük: Bulaşıcı Hastalıkların Aşılarla Yaygınlığının Azalmış Oluşu .74 b. Ebeveynlerin Kendi Müdahaleleriyle Bağışıklığını Güçlü Tutarak Çocuklarını Bulaşıcı Hastalıklardan Koruyacaklarına Olan İnanışları ………………………75 c. Çocuğuna Uygun Koşulları (Çevre, Hijyen Şartları) Sağlayarak Onu Bulaşıcı Hastalıklardan Koruma ………………………………………………………………………75 VII d. Risk Var ……………………………………………………………………79 e. Salgında Bulaşma Riski ……………………………………………………81 2. Bulaşıcı Hastalıkların Ciddiyetiyle İlgili Algılar ……………………………82 a. Algılanan Ciddiyetin Düşüklüğü …………………………………………..82 b. Algılanan Ciddiyetin Varlığı ………………………………………………84 c. Bazı Bulaşıcı Hastalıkların Daha Ciddi Olarak Algılanması ……………...85 d. Kişiye Göre Hastalığın Ciddiyetinin Değişmesi …………………………..87 e. Koşula Göre Hastalığın Ciddiyetini Değişmesi ……………………………88 f. Modern Tıp Gelişmiş Olduğu İçin Ciddiyetin Düşük Olarak Algılanması ..89 g. Kendi Müdahalesi ile Ciddiyetini Azalttığı İnanışı ………………………..90 E. SAĞLIKLA İLGİLİ İNANIŞLAR, YAPAY-DOĞAL AYRIMI ………………...92 1. Modern Tıbbın Yapay Olarak Algılanması …………………………………..92
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