Encountering Parents Who Are Hesitant or Reluctant to Vaccinate Their Children: A Meta-Ethnography
Abstract
:1. Introduction
2. Related Work
3. Materials and Methods
3.1. Design
3.2. Search Strategy
3.3. Search Outcomes
3.4. Quality Appraisal
3.5. Data Abstraction and Synthesis
4. Results
4.1. Characteristics of the Studies
4.2. Synthesis Results
4.2.1. Stone Hardness—Resistance to Vaccination
“I believe most critical parents are highly educated, difficult to drive an argument home to, having an own opinion but not always reading the scientific literature.”[38]
“It takes time to correct misunderstandings when the parents do not know that a study from Denmark showing that children could be at risk of autism after vaccination was fake.”Nurse; [41]
4.2.2. Lack of Modelling Tools—Lack of Resources, Support and Training
“We need more information on the vaccine, about the side effects, so that we can anticipate possible questions and reactions. So that we know what it’s about, simply. Vaccinating is something we’re used to, but this is an entirely new preparation.”Nurse; [35]
4.2.3. Rudimentary Sculpting—Using Personal Strategies
“(…) we do not have many unvaccinated [children], I have about three children. And I have, I have paid for it with high blood pressure, because I have perceived it as a personal failure.”Paediatrician; [33].
5. Discussion
Strengths and Limitations
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Aspect | Domain and Papers | Contribution |
---|---|---|
Reluctant or hesitant parents | Parental reasons for refusal or hesitation of vaccination [22,23] | The main parental reasons for not vaccinating their children are based on religious, personal or ideological reasons, safety concerns, and a desire for more information from healthcare providers. Lack of information and mistrust stand out as the main causes. |
Health workers and parents | Interventions [6,16,23,24,25,26] | Educational interventions on risks/benefits, changing the schedule of vaccinations, school-based programs, social norms with culturally tailored messages, and interventions at the physician level were the main interventions, despite the absence of promising results. These works emphasized that educational interventions can be counterproductive. Interventions that include presumptive, announcement language are more likely to be effective than those with participatory and conversational language. Moreover, educational interventions must be carefully tailored according to the target population, their reasons for hesitancy, and the specific context. Apart from the weak evidence regarding the interventions, health professionals reported problems with access to the materials developed to help them in these situations. |
Inclusion Criteria | Exclusion Criteria |
---|---|
| Gray literature, discussion or review papers |
Articles | Questions | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
Bašnáková and Hatoková (2017) [33] | ✓ | ✓ | ✓ | ✓ | - | ✗ | ✓ | ✓ | ✓ | ✓ |
Berry et al. (2017) [34] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Gottvall et al. (2011) [35] | ✓ | ✓ | ✓ | ✓ | ✓ | - | ✓ | ✓ | ✓ | ✓ |
Jama et al. (2019) [36] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Khan and Sahibzada (2016) [37] | ✓ | ✓ | ✓ | ✓ | ✓ | - | ✓ | ✓ | ✓ | ✓ |
Mollema et al. (2012) [38] | ✓ | ✓ | ✓ | ✓ | ✓ | - | ✓ | ✓ | ✓ | ✓ |
Navin et al. (2020) [39] | ✓ | ✓ | ✓ | ✓ | ✓ | - | ✓ | ✓ | ✓ | ✓ |
Omura et al. (2014) [40] | ✓ | ✓ | ✓ | ✓ | ✓ | ✗ | - | ✓ | - | ✓ |
Rudolfsson and Karlsson (2019) [41] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Ruijs et al. (2012) [42] | ✓ | ✓ | ✓ | ✓ | ✓ | ✗ | ✗ | ✓ | ✓ | ✓ |
Shahbari et al. (2020) [43] | ✓ | ✓ | ✓ | ✓ | ✓ | - | ✓ | ✓ | ✓ | ✓ |
Stretch et al. (2009) [44] | ✓ | ✓ | ✓ | ✓ | ✓ | - | ✓ | ✓ | ✓ | ✓ |
Authors (Year) Location | Methods | Aim | Sample | Type of Vaccination | Data Collection Method | Key Findings |
---|---|---|---|---|---|---|
Bašnáková and Hatoková (2017) [33] Slovakia | Qualitative study | To identify which communicative strategies Slovak paediatricians implicitly or explicitly choose in order to facilitate parental decisions about vaccination. | 15 primary care paediatricians | Mandatory childhood vaccination | In-depth interviews | Paediatricians typically lack formal training in communication with parents, but use a large number of effective communicative strategies that they have acquired during their clinical experience. However, often these decisions are not being made explicitly, and some paediatricians struggle with specific situations and types of parents. |
Berry et al. (2017) [34] Australia | Grounded theory | To understand the challenges faced and strategies used when general practitioners and immunising nurses encounter parents who choose not to vaccinate their children. | 17 general practitioners and 9 community and practice nurses | Childhood vaccination | In-depth interviews | Providers’ sense of professional identity as health advocates and experts became conflicted in their encounters with vaccine-objecting parents. Providers were dissatisfied when such consultations resulted in a “therapeutic roadblock”, whereby provider–parent communication came to a standstill. There were mixed views about being asked to sign forms exempting parents from vaccinating their children. These ranged from a belief that completing the forms rewarded parents for non-conformity to seeing it as a positive opportunity for engagement. Three common strategies were employed by providers to navigate through these challenges: (1) to explore and inform, (2) to mobilise clinical rapport and (3) to adopt a general principle to first do no harm to the therapeutic relationship. |
Gottvall et al. (2011) [35] Sweden | Qualitative study | To investigate school nurses’ perceptions of HPV immunization and their task of administering the vaccine in a planned school-based program in Sweden. | 30 school nurses | Human Papillomavirus (HPV) immunization | Focus groups | The school nurses saw the program as a benefit in that the free school-based HPV immunization program could balance out social inequalities. However, they questioned whether this new immunization program should be given priority given their already tight schedule. Some also expressed doubts regarding the effect of the vaccine. It was seen as challenging to obtain informed consent as well as to provide information regarding the vaccine. The nurses were unsure of whether boys and their parents should also be informed about the immunization. |
Jama et al. (2019) [36] Sweden | Explorative with inductive qualitative approach | To explore the perceptions, views and experiences of children’s health clinic nurses related to vaccine hesitancy in Rinkeby and Tensta. | 11 children’s health clinic Nurses | Measles-mumps-rubella (MMR) vaccination | In-depth interviews | Four themes emerged, namely hesitancy among Somali parents, lack of confidence in the MMR vaccine, loss of confidence in other vaccines due to mistrust of the MMR vaccine, and complacency regarding vaccination in general. |
Khan and Sahibzada (2016) [37] Pakistan | Qualitative study | To explore the challenges faced by health workers (HWs) during the polio health campaign. | 42 health workers (HWs) | Oral polio vaccine (OPV) | Focus groups | HWs disclosed that public attitude and harsh behaviour towards the HWs and security threats are the two main challenges they face. Common issues hindering parents’ willingness to vaccinate their children against OPV are that OPV is seen as haram and not permitted in Islam, it is said to contain the blood of pigs and monkeys, and parents are afraid that it is done to induce sterility among their children. HWs also shared that parents have a strong belief in the conspiracies that are associated with OPV, i.e., the USA and CIA are spying on us and our government is helping them to achieve their agenda. Furthermore, HWs revealed that frequent visits may further strengthen parents’ perceptions and make them more resistant to OPV. |
Mollema et al. (2012) [38] Netherlands | Exploratory qualitative study | To examine the factors behind the intentions to recommend current and future vaccinations to parents. | 25 child welfare centre nurses and physicians | Non-mandatory childhood immunization | Focus groups | Four main themes emerged, including (1) perceived responsibility: to promote vaccines and discuss pros and cons with parents (although this was usually not done if parents readily accepted the vaccination); (2) attitudes toward the NIP: mainly positive, but doubts remained as to NIP plans to vaccinate against diseases with a low perceived burden; (3) organizational factors: limited time and information can hamper discussions with parents; (4) relationship with parents: crucial and based mainly on communication to establish trust. |
Navin et al. (2020) [39] USA | Grounded theory | To attend to the activity and dispositions of the public health staff who provide “waiver education”. | 39 local health department staff (37 licensed nurses) | Routine childhood immunizations | Focus groups | Four themes emerged from analysis of the transcripts of these interviews: Participants had (1) complex and nuanced observations and evaluations of parents’ judgments and feelings about vaccines and vaccine education; (2) sympathetic attitudes about alternative vaccine schedules; (3) critical and supportive evaluations of institutional policies and the background political context of immunization education; and (4) consistent commitments to respect parents, affirm their values, and protect their rights. |
Omura et al. (2014) [40] Canada | Qualitative study | To explore the experiences of family physicians and paediatricians delivering immunizations, includingperceived barriers and supports. | 46 family physicians or general practitioners, 10 paediatricians and 2 residents | Routine childhood immunizations | Focus groups | Physicians highly valued vaccine delivery. Factors facilitating physician-delivered immunizations included strong beliefs in the value of vaccines and having adequate information. Identified barriers included the large time commitment and insufficient communication about program changes, new vaccines, and the adult immunization program in general. Some physicians reported good relationships with local public health, while others reported the opposite experience, and this varied by geographic location. |
Rudolfsson and Karlsson (2019) [41] Sweden | Qualitative study | To explore nurses’ experiences of encountering parents who are hesitant about or refrain from vaccinating their child. | 12 nurses from 7 child healthcare centres | Childhood vaccination | Individual, semi-structured interviews | Three themes emerged from the interviews: giving room and time for acknowledging parents’ insecurity concerning vaccination, striving to approach the parents’ position with tact, and a struggle between feelings of failure and respect for the parents’ view. The findings indicate that it was crucial to give time, be tactful when meeting parents, and to appear credible and up-to-date. The nurses wanted to be open and respect the parents’ views on vaccination but found it difficult and frustrating to be unable to reach out with their message because their quest was to protect the child. |
Ruijs et al. (2012) [42] Netherlands | Grounded theory | To gain insight into the response of healthcare professionals to parents with religious objections to the vaccination of their children. | 7 child health clinic doctors, 5 child health clinic nurses and 10 general practitioners | Childhood vaccination | Semi-structured interviews | Three manners of responding to religious objections to vaccination were identified: providing medical information, discussing the decision-making process, and adopting an authoritarian stance. All of the HCPs provided the parents with medical information. In addition, some HCPs discussed the decision-making process. They verified how the decision was made and, if possible, consequences were realized. Sometimes they also discussed religious considerations. Whether the decision-making process was discussed depended on the willingness of the parents to engage in such a discussion and on the religious background, attitudes, and communication skills of the HCPs. |
Shahbari et al. (2020) [43] Israel | Qualitative phenomenological research | To examine the impact of trust on the high response rate to vaccinations among the minority Arab population living in Israel. | 20 school nurses and nurses working in Family Health Centres (and 70 mothers) | Vaccination against seasonal flu and vaccination against the papilloma virus | Semi-structured interviews | The participants placed the highest trust in the nurses working in the Tipat Halav Family Health Centres run by the Ministry of Health. These nurses are the main communicators of information about childhood vaccinations in Israel. Moreover, the interviewees saw vaccinations as an example of the state offering equal and optimal services to the Arab minority population. In addition, the interviewees consider the explanatory materials to be limited, superficial and not culturally appropriate. |
Stretch et al. (2009) [44] UK | Qualitative study | To assess the feasibility and acceptability of providing human papillomavirus vaccination to 12–13-year-olds in 36 schools in Greater Manchester, in the northwest of England. | 15 school nurses | Routine human papillomavirus (HPV) vaccination | Semi-structured interviews | School nurses knew how to assess the competency of people under the age of 16 but were still unwilling to vaccinate if parents had refused permission. If parents had not returned the consent form, school nurses were willing to contact parents and also to negotiate with parents who had refused consent. They seemed unaware that parental involvement required the child’s consent to avoid breaking confidentiality. Nurses’ attitudes were influenced by the young appearance and age of the school year group rather than an individual’s level of maturity. They were also confused about the legal guidelines governing consent. School nurses acknowledged the child’s right to vaccination and strongly supported prevention of HPV infection but ultimately believed that it was the parents’ right to give consent. Most were themselves parents and shared other parents’ concerns about the vaccine’s novelty and unknown long-term side effects. Rather than vaccinate without parental consent, school nurses would defer vaccination. |
Summary of Review Findings | Studies Contributing to the Review Findings | Methodological Limitations | Coherence | Relevance | Adequacy of Data | Overall CERQual Assessment of Confidence | Explanation of Decision |
---|---|---|---|---|---|---|---|
Stone hardness—Resistance to vaccination | 33; 34; 35; 36; 37; 38; 39; 40; 41; 42; 43 | Minor concerns regarding methodological limitations, since there is a lack of clarity regarding the influence of the researcher on the investigation, and vice versa, as well as their possible influence during the data collection and analysis phases | Minor concerns regarding coherence (data very consistent within and across studies) | Moderate concerns regarding relevance, since there are studies in which the health systems are public and others are private, in addition to the fact that the parents who rejected vaccination belonged to very different cultural contexts | Very minor concerns about adequacy of data as the richness of data was generally good. The number of participants and studies is high | High confidence | Minor concerns about coherence and methodological limitations; moderate concerns about relevance; very minor concerns about adequacy of data |
Lack of modelling tools—Lack of resources, support and training | 34; 35; 38; 40; 41 | Minor concerns regarding methodological limitations, since there is a lack of clarity regarding the influence of the researcher on the investigation, and vice versa, as well as their possible influence during the data collection and analysis phases | Minor concerns regarding coherence (data very consistent within and across studies) | Moderate concerns regarding relevance, since there are studies in which the health systems are public and others are private, in addition to the fact that the parents who rejected vaccination belonged to very different cultural contexts | Moderate concerns, as the data were partially rich. Only a few studies in the sample examined in detail the lack of resources and support for healthcare professionals | Moderate confidence | Minor concerns about methodological limitations and coherence; moderate concerns about relevance and adequacy of the data |
Rudimentary sculpting—Using personal strategies | 33; 34; 38; 39; 40; 41; 42; 43; 44 | Minor concerns regarding methodological limitations, since there is a lack of clarity regarding the influence of the researcher on the investigation, and vice versa, as well as their possible influence during the data collection and analysis phases | Minor concerns regarding coherence (data very consistent within and across studies) | Moderate concerns regarding relevance, since there are studies in which the health systems are public and others are private, in addition to the fact that the parents who rejected vaccination belonged to very different cultural contexts | Moderate concerns, as the data were partially rich. Only some primary articles in the sample explained the use of their own strategies by health professionals | Moderate confidence | Minor concerns about methodological limitations and coherence; moderate concerns about relevance and adequacy of the data |
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Fernández-Basanta, S.; Lagoa-Millarengo, M.; Movilla-Fernández, M.-J. Encountering Parents Who Are Hesitant or Reluctant to Vaccinate Their Children: A Meta-Ethnography. Int. J. Environ. Res. Public Health 2021, 18, 7584. https://doi.org/10.3390/ijerph18147584
Fernández-Basanta S, Lagoa-Millarengo M, Movilla-Fernández M-J. Encountering Parents Who Are Hesitant or Reluctant to Vaccinate Their Children: A Meta-Ethnography. International Journal of Environmental Research and Public Health. 2021; 18(14):7584. https://doi.org/10.3390/ijerph18147584
Chicago/Turabian StyleFernández-Basanta, Sara, Manuel Lagoa-Millarengo, and María-Jesús Movilla-Fernández. 2021. "Encountering Parents Who Are Hesitant or Reluctant to Vaccinate Their Children: A Meta-Ethnography" International Journal of Environmental Research and Public Health 18, no. 14: 7584. https://doi.org/10.3390/ijerph18147584