A Meta-Synthesis Study of the Key Elements Involved in Childhood Vaccine Hesitancy

"Understanding the core elements of hesitancy will allow health professionals to adopt effective communication and behavioural strategies."

There is an increasing body of research work on vaccine hesitancy (VH), identifying this as a complex issue that presents multiple challenges that test the skills of health profesionals (HPs) responsible for vaccination. Included in this literature are quantitative systematic reviews. The present article summarises the qualitative evidence surrounding childhood VH from the perspective of parents; it also identifies the meta-themes surrounding a related concept, vaccine refusal (VR) from the perspective of parents.

The researchers searched for qualitative research articles on VH and VR in electronic databases from inception to March 2018. The process led to 27 articles meeting the inclusion criteria, involving a total of 1,557 parents who were hesitant about vaccinating their child. Of the 27 articles: 12 studies were conducted in the United States (US), Canada, and Venezuela; 9 refer to research conducted in Europe; 5 were from Australia; and 1 article was from Africa (Burkina Faso).

Five overarching categories were identified (an outline of the categories, subcategories, and meaningful quotations is set out in Table S2 in the article's supplementary material):

1. Risk conceptualisation - A key point to emerge from the 22 articles bearing this theme is that parents perceive vaccinations as a risk-bearing health treatment, and decision-making around this can be an agonising and worrisome one. This risk conceptualisation alone can lead to the decision not to vaccinate a child. There were 3 sub-categories that add granularity to how parents conceive risk: perceived risk of the vaccine; perceived contextual risk factors; and perceived risk of the target disease. "Risk appears to be a recurrent theme in studies investigating the phenomenon of VH and providers should be sufficiently knowledgeable to discuss parental concerns."
2. Mistrust - This category (22 articles) comprises 3 linked subcategories: mistrust towards institutions; questioning and doubting the integrity of HPs; and mistrust of "official" vaccine information. For example, some expressed their lack of trust in the media, which are mainly seen as supporting the medical establishment viewpoint on vaccines and not promoting and supporting an "open" debate about vaccine safety. Others "felt that some HPs were incompetent in their knowledge of vaccines and their side-effects. They also felt that there was a lack of time to discuss vaccines with HPs, but when they did, the communication style used was often paternalistic."
3. Parental alternative health beliefs - The articles (22) reflect 3 subcategories: beliefs about childhood immunity; beliefs about scheduling; and beliefs about "toxicity". Some scholars cited here "highlight the issue of providing information in time for parents to properly consider it and not at the same time the child attends for the vaccination appointment."
4. Philosophical views on parental responsibility - This theme, found in 18 articles, is connected to parents' world beliefs and is an issue that creates a sometimes conflicted set of issues related to the responsibility of making a complex decision for their child. The category includes 2 subcategories: the burden of responsibility; and spiritual and religious beliefs. One finding: "the burden of responsibility was associated with parents feeling judged and marginalized....[P]arents felt societal expectations influenced their vaccination decisions. The responsibility parents felt as a result of this vicarious decision-making was offset by turning to spiritual and religious beliefs and placing the fate of their child with God."
5. Parents' information levels about vaccination - This category (16 articles) includes 3 subcategories: lack of information; dealing with ambivalence; and reliance on alternative sources of information. In essence, parents reported not having enough information on which to make their vaccination decisions. More specifically, they reported a lack of balanced information, which influenced notions of mistrust. The absence of sufficient information also created feelings of ambivalence amongst parents, which is possibly fuelled by their reliance on alternative, unofficial channels via which to access information. Parents would often compare "official or medical information" with sources like the internet and lifestyle magazines without balancing the weight or quality of the reliability of the information.

These findings suggest that different approaches are required to counter the specific elements of VH/VR. In those cases in which the benefits and risks are misunderstood, the task may be simply to offer perspective and discuss the issues of benefit vs risk. However, because this belief may be compounded by a lack of trust in the honesty of researchers and clinicians, this adds another layer to the interaction. Building trust in parents is important in managing this; the HP might also explain the rigour of research and research governance to avoid conflicts of interest. Perhaps the most challenging are the parents who compound the above with an alternative health belief system. It may not be possible to overturn this viewpoint in a single healthcare interaction. The researchers suggest that more research on the development of interventions and strategies to approach this kind of entrenched VH. Qualitative research on how HPs deal with VH could also add to our understanding of how this issue may be approached in practice.

In conclusion, the review found that parental behaviour in relation to VR and/or VH is complex and multifaceted. "It should be remembered that underpinning this behaviour is often a desire to do what is felt to be right for the child"; thus, the researchers recommend that HPs approach difficult situations with parents from this perspective.