Factors influencing parental decision making when parents choose to deviate from the standard pediatric immunization schedule

Exploring Critical Factors Associated with Completion of Childhood Immunisation in the Eastern Province of Saudi Arabia

(1) Background: surveillance data from the Saudi Ministry of Health shows that the Kingdom’s large-scale immunisation programme has significantly reduced the mortality and morbidity of the target diseases among children. In this study, we review relevant literature and test a number of hypotheses related to the association between demographic, socio-economic, clinic-related, and parents-related variables and completion of childhood immunisation. In doing so, this study identifies critical factors associated with completion of childhood immunisation and presents important implications to healthcare practitioners, particularly in Saudi Arabia; (2) Literature review: a systematic literature review was conducted to understand what is currently published concerning parents’ immunisation compliance in Saudi Arabia and the factors associated with immunisation compliance. (3) Methods: from March to May 2022, an online survey was administered to parents attending one of the 27 primary health care (PHC) centres in Qatif. Data from parents (n = 353) were analysed using exploratory factor analysis, correlation, and a series of OLS and logistic regression models; (4) Results: parental (child) age was negatively (positively) associated with the completion status of childhood immunisation (both p < 0.05). Parents with positive attitudes, social norms, perceptions towards immunisation, and those working in private companies were more likely to immunise their children (all p < 0.05). Conversely, living in an apartment building, walking to PHCs, waiting longer at PHCs, and having higher knowledge of immunisation were negatively associated with the completion of childhood immunisation (all p < 0.05); (5) Conclusions: several factors that positively or negatively influence the completion of childhood immunisation have been identified. Future studies may investigate the causal link between these factors and parental decision-making regarding childhood immunisation.

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.

Parental Online Information Access and Childhood Vaccination Decisions in North America: Scoping Review

Background

Immunizing children throughout their early years prevents the spread of communicable disease and decreases the morbidity and mortality associated with many vaccine-preventable diseases. Searching online allows individuals rapid access to health information.

Objective

The purpose of this review was to develop an understanding of the existing literature of parents’ online health information-seeking behaviors to inform their vaccination choices for their children and to identify gaps in the literature around parents’ use of online health information and their vaccination choices.

Methods

A scoping review of peer-reviewed literature from Canada and the United States was performed. The following databases were utilized to perform the search: PubMed, CINAHL, Nursing & Allied Health Database, Scopus, and PsycINFO. The purpose of this review was to examine parents’ use of online information seeking related to vaccine information and to understand how parents utilize this information to inform decisions about vaccinating their children. Of the 34 papers included in the review, 4 relevant themes and subthemes were identified: information seeking, online information resources, online vaccine content, and trust in health care providers.

Results

Examination of the literature revealed conflicting information regarding parents’ use of social media and online resources to inform decisions around vaccinating their children. There is evidence of significant misinformation regarding vaccine risks online. Parents’ digital health literacy levels are unknown and may affect their ability to appraise online vaccination information.

Conclusions

Parents are seeking vaccine information from online sources. However, the influence of online vaccine information on parental vaccine practices remains uncertain.

Mistrust of the medical profession and higher disgust sensitivity predict parental vaccine hesitancy

Despite overwhelming evidence that vaccines are safe and effective, there has been a rise in vaccine hesitancy and refusal leading to increases in the incidence of communicable diseases. Importantly, providing scientific information about the benefits of vaccines has not been effective in counteracting anti-vaccination beliefs. Considering this, better identification of those likely to be vaccine hesitant and the underlying attitudes that predict these beliefs are needed to develop more effective strategies to combat anti-vaccination movements. Focusing on parents as the key decision makers in their children's vaccination, the aim of this study is to better understand the demographic and attitudinal predictors of parental vaccine hesitancy. We recruited 484 parents using Amazon MTurk and queried their attitudes on childhood vaccination, level of education, age, religiosity, political affiliation, trust in medicine, and disgust sensitivity. We found three main demographic predictors for parental vaccine hesitancy: younger age, lower levels of education, and greater religiosity. We also found vaccine hesitant parents to have significantly less trust in physicians and greater disgust sensitivity. These results provide a clearer picture of vaccine hesitant parents and suggest future directions for more targeted research and public health messaging.

Maternal perceptions of childhood vaccination: explanations of reasons for and against vaccination

BACKGROUND

Understanding reasons for and against vaccination from the parental perspective is critical for designing vaccination campaigns and informing other interventions to increase vaccination uptake in Canada. The objective of this study was to understand maternal vaccination decision making for children.

METHODS

Mothers participating in a longitudinal community-based pregnancy cohort, the All Our Babies study in Calgary, Alberta, completed open-ended survey questions providing explanations for the vaccination status of their child by 24 months postpartum. Qualitative responses were linked to administrative vaccination records to examine survey responses and recorded child vaccination status.

RESULTS

There were 1560 open-ended responses available; 89% (n = 1391) provided explanations for vaccinating their children, 5% (n = 79) provided explanations for not vaccinating/delaying, and 6% (n = 90) provided explanations for both. Themes were similar for those vaccinating and not vaccinating/delaying; however, interpretations were different. Two broad themes were identified: Sources of influence and Deliberative Processes. Sources of influence on decision making included personal, family, and external experiences. Deliberative Processes included risk, research, effectiveness, and balancing risks/benefits. Under Deliberative Processes, responsibility was a category for those vaccinating; while choice, instrumental/practical, and health issues were categories for those not vaccinating/delaying. Mothers' levels of conviction and motivation provided a Context for understanding their decision making perspectives.

CONCLUSIONS

Vaccination decision making is complex and impacted by many factors that are similar but contribute to different decisions depending on mothers' perspectives. The results of this study indicate the need to examine new intervention approaches to increase uptake that recognize and address feelings of pressure and parental commitment to choice.

Evaluation of Childhood Vaccine Refusal and Hesitancy Intentions in Turkey

OBJECTIVE

To assess the factors affecting parental childhood vaccine refusal and hesitancy (CVRH) intentions in Turkey.

METHODS

A total of 33 children's parents who were referred to two different child health care clinics because of CVRH and 99 controls were enrolled into this study from November through December 2017. The socio-demographic characteristics and perceptions of the parents who refused at least one vaccine for their child/children were compared with controls.

RESULTS

The monthly household income was significantly lower in CVRH group than control group. Refusal of the heel stick, refusal of hearing test, not using baby car seat, irregular use of vitamin D and iron prophylaxis, using alterative/complementary medicine, distrust in vaccines were the parameters which were found significantly higher in refused vaccine group than in control group. The beliefs "It may be dangerous for children" and "Distrust to the vaccines" were the most determined factors with a ratio of 51.5% in CVRH group.

CONCLUSIONS

This is the first study conducted to investigate the social-demographic characteristics and perception of parental CVRH in Turkey. The beliefs "It may be dangerous for the children" and "Distrust the vaccines" were the most determined factors which may affect CVRH. Some child health protective strategies were less undertaken in CVRH group than in controls; including heel stick test, hearing test, using baby car seat and using of Vitamin D and iron prophylaxis. The parents who have CVRH intentions tend to behave irresponsibly in care of their children.

Perceptions of caregivers and providers regarding the potential introduction of the varicella vaccine to the childhood immunisation schedule in New Zealand: A qualitative exploratory study

AIM

The varicella vaccine has been proposed to be added to the childhood immunisation schedule in New Zealand as the fourth injectable at the 15-month event. We sought to understand the perceptions of caregivers and health-care providers regarding the potential introduction of routine varicella vaccination.

METHODS

A qualitative exploratory study was conducted using semi-structured interviews with caregivers and providers (N = 20) in Auckland. Key themes from the interviews were identified through thematic analysis using a combination of deductive and inductive coding.

RESULTS

All of the participants were aware of varicella but levels of awareness varied among caregivers regarding the varicella vaccine. Participants expressed positive support towards universal varicella vaccination and a high intention to vaccinate if available as a routine vaccine. However, many concerns were raised about multiple injections at a single immunisation visit, and participants suggested alternative scheduling options.

CONCLUSION

The results indicated a need to raise awareness among caregivers about the varicella vaccine, focusing on positive health beliefs about vaccination in terms of protecting the child's health and reducing the impact of a child getting varicella on the family. Health-care providers and government health authorities may play an important role in increasing positive health beliefs about the varicella vaccine. Should the varicella vaccine be introduced as proposed, our findings recommend an educational campaign to address both caregiver and provider concerns about multiple injections and how to manage alternative immunisation schedules. These insights may help inform national strategies for the proposed addition to increase acceptance of the varicella vaccination.

Parents' and informal caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence

BACKGROUND

Childhood vaccination is an effective way to prevent serious childhood illnesses, but many children do not receive all the recommended vaccines. There are various reasons for this; some parents lack access because of poor quality health services, long distances or lack of money. Other parents may not trust vaccines or the healthcare workers who provide them, or they may not see the need for vaccination due to a lack of information or misinformation about how vaccinations work and the diseases they can prevent.Communication with parents about childhood vaccinations is one way of addressing these issues. Communication can take place at healthcare facilities, at home or in the community. Communication can be two-way, for example face-to-face discussions between parents and healthcare providers, or one-way, for instance via text messages, posters or radio programmes. Some types of communication enable parents to actively discuss vaccines and their benefits and harms, as well as diseases they can prevent. Other communication types simply give information about vaccination issues or when and where vaccines are available. People involved in vaccine programmes need to understand how parents experience different types of communication about vaccination and how this influences their decision to vaccinate.

OBJECTIVES

The specific objectives of the review were to identify, appraise and synthesise qualitative studies exploring: parents' and informal caregivers' views and experiences regarding communication about childhood vaccinations and the manner in which it is communicated; and the influence that vaccination communication has on parents' and informal caregivers' decisions regarding childhood vaccination.

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-process and Other Non-Index Citations (Ovid SP), Embase (Ovid), CINAHL (EbscoHOST), and Anthropology Plus (EbscoHost) databases for eligible studies from inception to 30 August 2016. We developed search strategies for each database, using guidelines developed by the Cochrane Qualitative Research Methods Group for searching for qualitative evidence as well as modified versions of the search developed for three related reviews of effectiveness. There were no date or geographic restrictions for the search.

SELECTION CRITERIA

We included studies that utilised qualitative methods for data collection and analysis; focused on the views and experiences of parents and informal caregivers regarding information about vaccination for children aged up to six years; and were from any setting globally where information about childhood vaccinations was communicated or distributed.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, using a three-step sampling frame. We conducted a thematic analysis using a constant comparison strategy for data extraction and synthesis. We assessed our confidence in the findings using the GRADE-CERQual approach. High confidence suggests that it is highly likely that the review finding is a reasonable representation of the phenomenon of interest, while very low confidence indicates that it is not clear whether the review finding is a reasonable representation of it. Using a matrix model, we then integrated our findings with those from other Cochrane reviews that assessed the effects of different communication strategies on parents' knowledge, attitudes and behaviour about childhood vaccination.

MAIN RESULTS

We included 38 studies, mostly from high-income countries, many of which explored mothers' perceptions of vaccine communication. Some focused on the MMR (measles, mumps, rubella) vaccine.In general, parents wanted more information than they were getting (high confidence in the evidence). Lack of information led to worry and regret about vaccination decisions among some parents (moderate confidence).Parents wanted balanced information about vaccination benefits and harms (high confidence), presented clearly and simply (moderate confidence) and tailored to their situation (low confidence in the evidence). Parents wanted vaccination information to be available at a wider variety of locations, including outside health services (low confidence) and in good time before each vaccination appointment (moderate confidence).Parents viewed health workers as an important source of information and had specific expectations of their interactions with them (high confidence). Poor communication and negative relationships with health workers sometimes impacted on vaccination decisions (moderate confidence).Parents generally found it difficult to know which vaccination information source to trust and challenging to find information they felt was unbiased and balanced (high confidence).The amount of information parents wanted and the sources they felt could be trusted appeared to be linked to acceptance of vaccination, with parents who were more hesitant wanting more information (low to moderate confidence).Our synthesis and comparison of the qualitative evidence shows that most of the trial interventions addressed at least one or two key aspects of communication, including the provision of information prior to the vaccination appointment and tailoring information to parents' needs. None of the interventions appeared to respond to negative media stories or address parental perceptions of health worker motives.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several review findings. Further research, especially in rural and low- to middle-income country settings, could strengthen evidence for the findings where we had low or very low confidence. Planners should consider the timing for making vaccination information available to parents, the settings where information is available, the provision of impartial and clear information tailored to parental needs, and parents' perceptions of health workers and the information provided.

Addressing Parental Vaccination Questions in the School Setting: An Integrative Literature Review

School nurses work in a unique environment with key opportunities to address parental concerns and questions regarding their child's health. A common concern for parents during school enrollment is childhood vaccination safety and efficacy. As public health leaders, school nurses are well respected among parents, therefore school nurses are in a prime position to educate parents and promote childhood vaccinations while also dispelling common vaccination myths. The purpose of this integrative literature review is to synthesize evidence-based answers to common parental questions regarding childhood vaccinations.

Vaccination uptake by vaccine-hesitant parents attending a specialist immunization clinic in Australia

Vaccine hesitancy (VH) is an issue of global concern. The quality of communication between healthcare providers and parents can influence parental immunization acceptance. We aimed to describe immunization uptake following specialist immunization clinic (SIC) consultation for Australian children of VH parents as a cohort, and according to pre-clinic parental position on immunization. At a single tertiary pediatric SIC (RCH, Melbourne) a retrospective descriptive study classified VH families according to 3 proposed parental positions on immunization at initial clinic attendance. Immunization status at follow up was ascertained via the Australian Children's Immunization Register and National HPV Program Register and compared between groups. Of the VH cohort, 13/38 (34%) families were classified as hesitant, 21 (55%) as late/selective vaccinators and 4 (11%) as vaccine refusers. Mean follow up post-SIC attendance was 14.5 months. For the overall VH cohort, the majority chose selective immunization (42%) following SIC consultation. When analyzed by pre-clinic parental position on immunization, there was a trend for hesitant families to proceed with full immunization, selective families to continue selective immunization and refusing families to remain unimmunised (p < 0.0001). The most commonly omitted vaccines were hepatitis B (66%) and Haemophilus influenzae type B (55%), followed by the meningococcal C conjugate vaccine (53%) and measles, mumps and rubella vaccine (53%). Immunization outcome appears to correlate with pre-clinic parental position on immunization for the majority of families attending a SIC in Australia, with selective immunization the most common outcome. Tailored communication approaches based on parental position on immunization may optimise clinic resources and engagement of families, but require prospective research evaluation.

What Parents Need to Know About Vitamin K Administration at Birth

Prophylactic treatment of newborns with intramuscular vitamin K has been the standard of care for many years in the United States. However, instances of parental refusal of routine prophylaxis are currently on the rise. Refusal of routine prophylaxis can have serious long-term neurodevelopmental consequences for some newborns, who may subsequently develop vitamin K deficiency-associated hemorrhagic disease of the newborn (HDN).

Physician response to parental requests to spread out the recommended vaccine schedule

OBJECTIVES

To assess among US physicians (1) frequency of requests to spread out recommended vaccination schedule for children <2 years, (2) attitudes regarding such requests, and (3) strategies used and perceived effectiveness in response to such requests.

METHODS

An e-mail and mail survey of a nationally representative sample of pediatricians and family physicians from June 2012 through October 2012.

RESULTS

The response rate was 66% (534 of 815). In a typical month, 93% reported some parents of children <2 years requested to spread out vaccines; 21% reported ≥ 10% of parents made this request. Most respondents thought these parents were putting their children at risk for disease (87%) and that it was more painful for children (84%), but if they agreed to requests, it would build trust with families (82%); further, they believed that if they did not agree, families might leave their practice (80%). Forty percent reported this issue had decreased their job satisfaction. Most agreed to spread out vaccines when requested, either often/always (37%) or sometimes (37%); 2% would often/always, 4% would sometimes, and 12% would rarely dismiss families from their practice if they wanted to spread out the primary series. Physicians reported using a variety of strategies in response to requests but did not think they were effective.

CONCLUSIONS

Virtually all providers encounter requests to spread out vaccines in a typical month and, despite concerns, most are agreeing to do so. Providers are using many strategies in response but think few are effective. Evidence-based interventions to increase timely immunization are needed to guide primary care and public health practice.

Understanding parental participation in health promotion services for their children

The aim of this research was to explore parental participation in child health promotion services within a Hong Kong community. There are many elements influencing the effect of health promotion services. One is the extent of parental participation. However, research in this area is limited. Focus group data were content analyzed. Six themes were conceptualized. They are Equity, Equality, Evolution, Engagement, Consultation, and Continuity. We concluded that a strategic approach in partnership with families is required for health promotion activities for children. The findings contribute to an understanding of the crucial factors for the promotion of parental participation in health promotion services.

Caregivers who refuse preventive care for their children: the relationship between immunization and topical fluoride refusal

OBJECTIVES

The aim of this study was to examine caregivers' refusal of preventive medical and dental care for children.

METHODS

Prevalence rates of topical fluoride refusal based on dental records and caregiver self-reports were estimated for children treated in 3 dental clinics in Washington State. A 60-item survey was administered to 1024 caregivers to evaluate the association between immunization and topical fluoride refusal. Modified Poisson regression models were used to estimate prevalence rate ratios (PRRs).

RESULTS

The prevalence of topical fluoride refusal was 4.9% according to dental records and 12.7% according to caregiver self-reports. The rate of immunization refusal was 27.4%. In the regression models, immunization refusal was significantly associated with topical fluoride refusal (dental record PRR = 1.61; 95% confidence interval [CI] = 1.32, 1.96; P < .001; caregiver self-report PRR = 6.20; 95% CI = 3.21, 11.98; P < .001). Caregivers younger than 35 years were significantly more likely than older caregivers to refuse both immunizations and topical fluoride (P < .05).

CONCLUSIONS

Caregiver refusal of immunizations is associated with topical fluoride refusal. Future research should identify the behavioral and social factors related to caregiver refusal of preventive care with the goal of developing multidisciplinary strategies to help caregivers make optimal preventive care decisions for children.

Why parents refuse childhood vaccination: a qualitative study using online focus groups

Background

In high income countries, vaccine-preventable diseases have been greatly reduced through routine vaccination programs. Despite this success, many parents question, and a small proportion even refuse vaccination for their children. As no qualitative studies have explored the factors behind these decisions among Dutch parents, we performed a study using online focus groups.

Methods

In total, eight online focus groups (n = 60) which included Dutch parents with at least one child, aged 0–4 years, for whom they refused all or part of the vaccinations within the National Immunization Program (NIP). A thematic analysis was performed to explore factors that influenced the parents’ decisions to refuse vaccination.

Results

Refusal of vaccination was found to reflect multiple factors including family lifestyle; perceptions about the child’s body and immune system; perceived risks of disease, vaccine efficacy, and side effects; perceived advantages of experiencing the disease; prior negative experience with vaccination; and social environment. The use of online focus groups proved to be an effective qualitative research method providing meaningful data.

Conclusion

Information provided by the NIP turned out to be insufficient for this group of parents. More trust in the NIP and deliberate decisions might result from increased parental understanding of lifestyle and disease susceptibility, the impact of vaccinations on the immune system, and the relative risks of diseases and their vaccines. The public health institute should also inform parents that the NIP is recommended but non-mandatory.