Health literacy and attitudes to vaccination among adults in Eastern Croatia

Background

Vaccine hesitancy and declining coverage threaten control of vaccine-preventable diseases, while limited health literacy may fuel uncertainty about vaccine safety and effectiveness. This study assessed health literacy and attitudes toward vaccination among adults in Eastern Croatia and their links with sociodemographic characteristics and influenza and COVID-19 vaccination status.

Methods

A cross-sectional online survey was conducted among adults (≥18 years) in Eastern Croatia between January and April 2024 using snowball sampling. The questionnaire covered sociodemographic and socioeconomic data, six Likert-scale items (1–5) on vaccination attitudes, dichotomous questions on influenza and COVID-19 vaccination, and the Croatian HLS-EU-Q16 instrument. Scores (0–64) were categorised as inadequate (0–32), problematic (33–48) or adequate (49–64). Data were analysed with non-parametric tests (Mann–Whitney U, Kruskal–Wallis, Fisher’s exact, p < 0.05).

Results

Of 513 respondents, 74.3% were women, median age 43 years (IQR 30–54); 70.0% had higher or university education and 78.5% were employed. Attitudes toward vaccination were predominantly positive; 73.7% were vaccinated against COVID-19, while 71.5% had never been vaccinated against influenza. Health literacy was inadequate in 7.4%, problematic in 50.6% and adequate in 42.0%. More positive attitudes were associated with higher health literacy, higher self-assessed socioeconomic status and prior vaccination against influenza and COVID-19 (p < 0.05). A positive association was also observed between health literacy and COVID-19 vaccination status.

Conclusions

Adults in Eastern Croatia generally show favourable attitudes toward vaccination, yet over half have problematic health literacy. Higher health literacy is linked to more positive vaccination views and higher COVID-19 uptake, underlining the need for targeted interventions to strengthen health literacy and support vaccine confidence and coverage.

Key messages

• Targeted health-literacy interventions in primary care and community settings should prioritise adults with lower socioeconomic status and low influenza uptake to close vaccination gaps.

• Scaling up workplace and primary-care health-literacy interventions, with culturally adapted materials in Croatian, could raise influenza coverage and reinforce sustained COVID-19 vaccine confidence.