The pros and cons of immunisation

Determinants of SARS-CoV-2 vaccine willingness among people incarcerated in 3 Canadian federal prisons: a cross-sectional study

BACKGROUND

Maximizing uptake of SARS-CoV-2 vaccines among people in prison is essential in mitigating future outbreaks. We aimed to determine factors associated with willingness to receive SARS-CoV-2 vaccination before vaccine availability.

METHODS

We chose 3 Canadian federal prisons based on their low uptake of influenza vaccines in 2019-2020. Participants completed a self-administered questionnaire on knowledge, attitude and beliefs toward vaccines. The primary outcome was participant willingness to receive a SARS-CoV-2 vaccine, measured using a 5-point Likert scale to the question, "If a safe and effective COVID-19 vaccine becomes available in prison, how likely are you to get vaccinated?" We calculated the association of independent variables (age, ethnicity, chronic health conditions, 2019-2020 influenza vaccine uptake and prison security level), identified a priori, with vaccine willingness using logistic regression and crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We recruited 240 participants from Mar. 31 to Apr. 19, 2021 (median age 46 years; 19.2% female, 25.8% Indigenous). Of these, 178 (74.2%) were very willing to receive a SARS-CoV-2 vaccine. Participants who received the 2019-2020 influenza vaccine (adjusted OR 5.20, 95% CI 2.43-12.00) had higher odds of vaccine willingness than those who did not; those who self-identified as Indigenous (adjusted OR 0.27, 95% CI 0.11-0.60) and in medium- or maximum-security prisons (adjusted OR 0.36, 95% CI 0.12-0.92) had lower odds of vaccine willingness than those who identified as white or those in minimum-security prisons, respectively.

INTERPRETATION

Most participants were very willing to receive vaccination against SARS-CoV-2 before vaccine roll-out. Vaccine promotion campaigns should target groups with low vaccine willingness (i.e., those who have declined influenza vaccine, identify as Indigenous or reside in high-security prisons).

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

The politics of picking: Selective vaccinators and population-level policy

•Public health systems face tensions between individuals and the collective•Parents who selectively vaccinate demonstrate this tension•Parents in this study want vaccination programs to run differently•Implementing their wishes could put the system at risk.

The Social Basis of Vaccine Questioning and Refusal: A Qualitative Study Employing Bourdieu's Concepts of 'Capitals' and 'Habitus'

This article is an in-depth analysis of the social nature of vaccine decision-making. It employs the sociological theory of Bourdieu and Ingram to consider how parents experience non-vaccination as a valued form of capital in specific communities, and how this can affect their decision-making. Drawing on research conducted in two Australian cities, our qualitative analysis of new interview data shows that parents experience disjuncture and tugs towards 'appropriate' forms of vaccination behavior in their social networks, as these link to broader behaviors around food, school choices and birth practices. We show how differences emerge between the two cities based on study designs, such that we are able to see some parents at the center of groups valorizing their decisions, whilst others feel marginalized within their communities for their decisions to vaccinate. We draw on the work of philosopher Mark Navin to consider how all parents join epistemic communities that reward compliance and conformity with the status quo and consider what this means for interventions that seek to influence the flow of pro-vaccine information through vaccine-critical social groups.

'The Unhealthy Other': How vaccine rejecting parents construct the vaccinating mainstream

To address the phenomenon of vaccine hesitancy and rejection, researchers increasingly recognise the need to engage with the social context of parents' decision-making. This study examines how vaccine rejecting parents socially construct the vaccinating mainstream in opposition to themselves. We analyse qualitative data from interviews with parents in Adelaide, South Australia. Applying insights from Social Identity Theory (SIT), we show how these parents bolster their own sense of identity and self-belief by employing a discourse that casts vaccinators as an Unhealthy Other. We demonstrate how the parents identify vaccination as a marker of parental conformity to the 'toxic practices of mass industrial society', linking it to other ways in which membership of the consumerist mainstream requires individuals to 'neglect their health.' This is explored through themes of appearance, diet, (over) consumption of pharmaceuticals, inadequate parenting values and wilful or misguided ignorance. This construction of the Unhealthy Other elevates the self-concept of vaccine hesitant and rejecting parents, who see themselves as part of an enlightened, but constantly besieged, group of healthy and virtuous parents. It is common for the vaccinating mainstream to present vaccine hesitant and rejecting parents as a group subject to epistemic closure, groupthink, confirmation bias and over-confidence in their own expertise. However, vaccine hesitant and rejecting parents also see mainstream society as a group-a much larger one-subject to the same problems. We suggest the need to mitigate the 'groupness' of vaccination and non-vaccination by extending the practice of vaccination to recognisable practitioners of holistic health.

Parenting as politics: social identity theory and vaccine hesitant communities

Purpose

The purpose of this paper is to develop a theoretical framework for understanding the identity politics associated with parental hesitancy and refusal of vaccines for their children (“vaccine hesitancy or refusal” or “VHR”). Understanding these identity politics helps policymakers to craft appropriate communication interventions that do not make the problem worse.

Design/methodology/approach

Social identity theory is a way of understanding how group identities develop around the lifestyle practices that often include refusal to vaccinate, and how this group identity is accentuated by conflict with the pro-vaccinating societal mainstream. This paper critically appraises existing studies of VHR to explore this groupness across many different contexts.

Findings

Groupness is evident across many different contexts. There are also key group characteristics: preference for natural birth and breastfeeding, nature as a concept and use of complementary and alternative medicine.

Research limitations/implications

The paper is speculative and theoretical, using existing sources. Future studies will need to demonstrate empirically with new data. However, this theoretical approach sets up a new research agenda.

Social implications

These findings can help governments and policymakers minimise social conflict that risks further polarising vaccine conversations and wedging parents on the fence.

Originality/value

This paper argues that the decision to vaccinate or not is an inherently social one, not a matter of pure individual rationality. This is a novel approach to engaging with what is often characterised and studied as an individual decision.

Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: influence, impact and implications

Despite being recognized as one of the most successful public health measures, vaccination is perceived as unsafe and unnecessary by a growing number of parents. Anti-vaccination movements have been implicated in lowered vaccine acceptance rates and in the increase in vaccine-preventable disease outbreaks and epidemics. In this review, we will look at determinants of parental decision-making about vaccination and provide an overview of the history of anti-vaccination movements and its clinical impact.

Vaccine refusal and the endgame: walking the last mile first

As multiple papers within this special issue illustrate, the dynamics of disease eradication are different from disease control. When it comes to disease eradication, 'the last mile is longest'. For social and ecological reasons such as vaccine refusal, further ending incidence of a disease when it has reached low levels is frequently complex. Issues of non-compliance within a target population often influence the outcome of disease eradication efforts. Past eradication efforts confronted such obstacles towards the tail end of the campaign, when disease incidence was lowest. This article provides a comparison of non-compliance within polio, measles and smallpox campaigns, demonstrating the tendency of vaccine refusal to rise as disease incidence falls. In order to overcome one of the most intractable challenges to eradication, future disease eradication efforts must prioritize vaccine refusal from the start, i.e. 'walk the last mile first'.

Vaccine hesitancy: an overview

Despite being recognized as one of the most successful public health measures, vaccination is perceived as unsafe and unnecessary by a growing number of individuals. Lack of confidence in vaccines is now considered a threat to the success of vaccination programs. Vaccine hesitancy is believed to be responsible for decreasing vaccine coverage and an increasing risk of vaccine-preventable disease outbreaks and epidemics. This review provides an overview of the phenomenon of vaccine hesitancy. First, we will characterize vaccine hesitancy and suggest the possible causes of the apparent increase in vaccine hesitancy in the developed world. Then we will look at determinants of individual decision-making about vaccination.

Making sense of perceptions of risk of diseases and vaccinations: a qualitative study combining models of health beliefs, decision-making and risk perception

Background

Maintaining high levels of childhood vaccinations is important for public health. Success requires better understanding of parents' perceptions of diseases and consequent decisions about vaccinations, however few studies have considered this from the theoretical perspectives of risk perception and decision-making under uncertainty. The aim of this study was to examine the utility of subjective risk perception and decision-making theories to provide a better understanding of the differences between immunisers' and non-immunisers' health beliefs and behaviours.

Methods

In a qualitative study we conducted semi-structured in-depth interviews with 45 Australian parents exploring their experiences and perceptions of disease severity and susceptibility. Using scenarios about 'a new strain of flu' we explored how risk information was interpreted.

Results

We found that concepts of dread, unfamiliarity, and uncontrollability from the subjective perception of risk and ambiguity, optimistic control and omission bias from explanatory theories of decision-making under uncertainty were useful in understanding why immunisers, incomplete immunisers and non-immunisers interpreted severity and susceptibility to diseases and vaccine risk differently. Immunisers dreaded unfamiliar diseases whilst non-immunisers dreaded unknown, long term side effects of vaccines. Participants believed that the risks of diseases and complications from diseases are not equally spread throughout the community, therefore, when listening to reports of epidemics, it is not the number of people who are affected but the familiarity or unfamiliarity of the disease and the characteristics of those who have had the disease that prompts them to take preventive action. Almost all believed they themselves would not be at serious risk of the 'new strain of flu' but were less willing to take risks with their children's health.

Conclusion

This study has found that health messages about the risks of disease which are communicated as though there is equality of risk in the population may be unproductive as these messages are perceived as unbelievable or irrelevant. The findings from this study have implications beyond the issue of childhood vaccinations as we grapple with communicating risks of new epidemics, and indeed may usefully contribute to the current debate especially in the UK of how these theories of risk and decision-making can be used to 'nudge' other health behaviours.

Addressing parents' concerns about childhood immunizations: a tutorial for primary care providers

BACKGROUND

Despite the dangers of vaccine-preventable infections and efforts by health care professionals to promote immunization, parents' resistance to routine childhood immunizations continues to grow. This phenomenon can give rise to frustration among health care providers, as well as create barriers in providing medical care to children in need. In response, we developed a CD-ROM-based tutorial that (1) explains the nature and origins of parents' concerns, (2) addresses clinical implications of resistance to immunization, (3) explores ethical and professional obligations that physicians have toward children and their parents, and (4) discusses how physicians can effectively address parents' concerns.

OBJECTIVE

Our goals were to evaluate the tutorial's effectiveness in improving physicians' (1) general knowledge about parents' resistance to childhood immunizations, (2) knowledge of adverse effects of immunization, and (3) attitudes toward parents' resistance to childhood immunization.

DESIGN/METHODS

After pretesting, expert review, and revision, the 45-minute Penn State Immunization Project tutorial was pilot tested with pediatric and family medicine residents at 7 training programs in 4 states (Pennsylvania, New York, Maryland, and Iowa). Knowledge and attitudes were assessed by using a 26-item pretest/posttest, the results of which were then analyzed by using standard statistical methods.

RESULTS

A total of 122 residents completed the pretest/posttest. Statistically and clinically significant improvements were seen in residents' general knowledge, knowledge of adverse events, and all 5 attitudinal measures regarding childhood immunizations.

CONCLUSIONS

The tutorial Addressing Parents Concerns About Childhood Immunizations: A Tutorial for Primary Care Providers is effective in improving resident physicians' general knowledge, knowledge of adverse events, and attitudes. As such, this tutorial has the potential to enhance communication between parents and primary care providers and, more generally, improve clinicians' response to the growing resistance toward routine childhood immunizations.

An attempt to swindle nature: press anti-immunisation reportage 1993-1997

There is some evidence that low childhood immunisation rates in Australia may be attributed partly to parental antipathy toward immunisation. The anti-immunisation movement is becoming more organised in its efforts to lobby against childhood immunisation, while the lessening of the public's exposure to the effects of vaccine-preventable disease has provided a climate ripe for such a lobby to have a disproportionate influence on parents. Forty months of Australian print media coverage of immunisation were reviewed for anti-immunisation arguments and their underlying ideological subtexts. Of 2440 articles about childhood immunisation, 115 (4.7 per cent) contained statements opposing immunisation. Eight subtexts that referenced wider discourses about medicine, the state and the body dominated anti-immunisation discourse (cover-up; excavation of the facts; unholy alliance for profit; towards totalitarianism; us and them; vaccines as poisonous chemical cocktails; vaccines as cause of idiopathic ills; and back to nature). Attempts to redress claims made against immunisation must not only address specific claims about vaccine efficacy and safety but be grounded in a reframing of the ideological appeals that currently frame the contents of anti-immunisation discourse.