Professional Documents
Culture Documents
Emily Eckman, Kirstie Lewis, Alex Rich, Amanda Rupp, Michael Sheridan
04/03/2017
Abstract
The purpose of this research was to examine the factors that influence vaccine hesitancy among
parents of children six years of age and younger. Specific demographic information such as
gender, education level, and socioeconomic status were studied, as well as patient fears and
changing attitudes towards vaccines. The research provided was obtained from 16 sources with
some literature reviews and qualitative studies. It was found that there was substantial evidence
correlation between vaccine refusal and specific demographic information. There was no
definite evidence to suggest long term effects of unvaccinated children. Overall, the research
concluded that many factors contribute to vaccine hesitancy and increased efforts are needed by
health professionals to ensure all vaccines are administered at the appropriate time.
FACTORS INFLUENTING VACCINE HESITANCY 3
Over recent years, vaccine hesitancy has become a very prevalent and dangerous issue all
over the world. According to Blaisdell, L. L., Gutheil, C., Hootsmans, N. A., & Han, P. K.
delay, and alternative schedules” (p. 479). The decreased confidence toward vaccinations is
threatening the success of vaccination programs and making outbreaks more common. Due to
this growing issue, new research has been developed regarding the determinants that impact the
vaccination decisions of parents. Overall results show that vaccine decisions—just as any other
parental decision—are seldom made on their own. Therefore, the following research question is
addressed: In parents of children 6 years and younger, what are factors that contribute to
Literature Review
Introduction
To address this problem in the healthcare profession, information was obtained through
several online sources, including Google Scholar, PubMed, American Academy of Pediatrics, the
World Health Organization, and the Centers for Disease Control and Prevention. Sixteen sources
were studied for extensive data collection in regards to factors that influence parents not to
vaccinate their children and reasons that parents that are cautious about childhood
immunizations. Trends, social influences, physical factors, and emotional fears are examined, as
Healthy People 2020 goals include maintaining at least 90% of immunization coverage in
children up to 35 months of age in the United States. Although the standard childhood
immunization statistics have remained relatively stable over the last decade, the coverage
objective in 2014-2015 was only met for certain vaccinations. These vaccines include
poliovirus, MMR, HepB, and varicella. Target objectives were not met for the combined series
immunizations of DTaP, Hib, and PCV. According to the Healthy People 2020’s report,
increased efforts are needed to provide the final series of these shots because the final dose for
these immunizations is often scheduled during the second year of life, when routine visits to
health care providers occur less frequently (Hill, H., Elam-Evans, L., Yankey, D., Singleton, J.,
The Healthy People 2020 report for 2015 surveyed estimates state by state. According to
Hill et al. (2016), the state with the most MMR coverage was found in Maine at 97.2%. This
figure has increased by 6.2% since 2013. Arizona had the lowest estimated coverage at 84.1%.
Maine also had the highest DTaP coverage at 93.1%, while Wyoming ranked the lowest at
72.8%. The rotavirus vaccine saw increases in coverage as compared with the 2013 statistics in
years of age, it was concluded that 79% were “confident” or “very confident” in the safety of
standard childhood immunizations (Kennedy, A., Basket, M., Sheedy, K., 2010). The same
survey performed in 2010 found that 72% of parents were confident in vaccine safety (Kennedy
FACTORS INFLUENTING VACCINE HESITANCY 5
et al., 2010). Approximately one in five parents had hesitations about the safety or importance of
immunizations. Acceptance of newly recommended vaccines such as the rotavirus and influenza
immunizations has been sluggish. According to Gowda et al., (2013), a national study of parents
was completed in 2000 indicating 19% of parents had concerns about vaccines. By 2009, this
While the majority of parents understand the necessity of timely vaccinations for their
children, many times variance from the recommended schedule can lead to spikes in occurrences
of these once-eradicated illnesses. For example, a 2010 National survey of physicians was
performed, with 89% of participants noting at least one childhood immunization refusal per
month, as well as an estimated 16% of parents requested an alternate vaccine schedule for at
least one vaccine (Gowda, C., Dempsey, A., 2013). In 2012, 93% of participating physicians
indicated that parents with children younger than two years of age asked to spread out vaccine
administration (Gowda et al., 2013). A growing number of children are being put on an altered
immunization schedule due to parental vaccine hesitancy. This practice results in “unnecessarily
increased periods of ‘risk exposure’ for contracting a vaccine-preventable disease” (Gowda et al.,
2013). The United States recorded 140 cases of measles in 2008, which was more than twice the
number of cases from 2000-2007. The cause was determined to be larger viral transmission
between unvaccinated people. According to Gowda et al. (2013), another measles outbreak was
vaccine hesitancy can also lead to health hazards. Gowda et al. (2013), found that the
elimination of the measles endemic in 2000 has parents questioning if there is a continued need
for the measles immunization. Some parents assume that their children will have less risk of
FACTORS INFLUENTING VACCINE HESITANCY 6
contracting the disease due to herd immunity. Others feel that their children will benefit from
acquiring the immunity through naturally contracting the disease instead of vaccine-produced
immunity.
An unvaccinated child will cope with lifelong challenges in health status, medical
treatment, and social interactions. However, children who are unvaccinated or under-vaccinated
are not the only individuals who will be affected by their decision. Choosing that a child will not
get vaccinations also raises many questions and potential problems. Will insurance companies
cover medical expenses for a preventable illness? Will schools allow the child to attend without
being vaccinated, or will the child need to have special allowances made to protect them from
possible illness? How will the inevitable rising cost of healthcare due to vaccine-preventable
disease affect insurance costs for the average American? How will this growing problem modify
nursing and healthcare professionals regarding standard precautions, additional education, and
increasing staff needs? How many children will perish unnecessarily because they did not
receive a vaccine? These questions remain unanswered as physicians, nurses, and other pro-
Social Influences
One of the most dominant factors that affects vaccine hesitancy in parents of children six
years old and younger includes social influences. Social influences consist of many factors, such
as surrounding opinions of others, social networks and internet sources. First of all, healthcare
providers are part of surrounding opinions that impact vaccine decision making, including
primarily physicians and nurses. Many studies examined for this literature review aimed to rank
social influences that impact the decisions of both vaccine confident and vaccine hesitant
FACTORS INFLUENTING VACCINE HESITANCY 7
parents. Such as a study conducted by Dube, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., &
Bettinger, J.A. (2013), which shows that healthcare providers are the second most influential
factor and the first most trusted source of information regarding vaccine decision making. (p.
1767). Also within a cross-sectional study by Chen, M., Wang, R., Schneider, J. K., Tsai, C.,
Jiang, D. D., Hung, M., & Lin, L. (2011), the top two influences that parents chose on their
children for influenza” and “My nurse(s) recommendation affected my decision whether to
Two other major social influences that effect parental decisions regarding vaccination are
the beliefs of their family and friends. For example, within two different studies, spouses were
ranked as the number one most influential social determinant of vaccine decision making. While
also ranking family members in third and friends in fourth for both vaccine confident and
hesitant parents (Dube et al., 2013; Brunson, E. K. 2013). Family and friends have many
different ways of influencing the decision of childhood vaccination. Such as, within the
quantitative study developed by Harmsen I. A., Ruiter, R. A., Paulussen, T.G., Mollema, L.,
Kok, G., and deMelker, H. E. (2012), parents of three focus groups reported their family and
Another social factor that plays a major rule in contributing to vaccine hesitancy is the
internet. Surprisingly, even when parents discuss childhood vaccine information with their
healthcare providers, the majority of them still refer to the internet for further information
sources (Dube et al., 2013, p. 1766). These online sources may of course include credible and
non-credible information. When researching vaccine information via the internet, there is a large
59% of online sources are against a normal childhood vaccinations, while only 20% support it.
The online sources against it promote information that suggest not following an on-time or full
vaccination schedules (Brunson, E. K. 2013, p. 4). Another major difference regarding the
internet exists between vaccine hesitant and vaccine confident parents. Parents who choose to
delay or refuse vaccinating their children are more likely to have searched the internet for
information. In addition, parents who search through anti-vaccination websites for at least five
minutes gain a negative impact on their decision due to increased risk perception (Dube et al.,
2013, p. 1766).
Additionally, social networking sites have not only become part of everyday life, but also
part of vaccine decision-making. As explained by Dube et al. (2013), these sites have given anti-
vaccine activists a platform to speak their opinions and allow for quicker spreading of inaccurate
information. Most of all, the narrated stories on these sites add a new dimension to online health
sources, including “a personal and embodied view of vaccine-preventable disease, vaccines and
their potential (often negative) consequences”. This explains why vaccine hesitant parents are
more likely have used social networking sites as part of their information source, as compared to
vaccine confident parents (p.1766). Also caregivers who agree that mass media
recommendations affect their daily decisions are significantly less likely to have their children
vaccinated. A possible explanation for this is that negative information has a stronger and more
lasting impact on parents as opposed to positive information. For example, parents are more
Physical Factors
After researching literature of physical factors that have an effect on children getting
completely vaccinated, studies show that factors such as income, educational level, and race or
ethnicity have a big impact on whether a child is vaccinated. The first influential element is the
educational level in mothers and how that effects whether a child gets all their vaccines or not. A
study from US National Library of Medicine National Institutes of Health shows that out of
13,558 mothers included in the survey, only 6,982 mothers were able to provide information
regarding polio vaccinations. (Khan, M., Zaheer, S., & Shafique, K., 2017). This finding shows
that some mothers were not educated on vaccines for children so were more than likely not to get
their children vaccinated. Also, Khan et al., (2017) states the following:
Only 56.4% out of 6, 982 of the children received complete polio vaccination. Women
with no educational background significantly had higher odds of their child receiving no
significantly higher odds of not taking their child for any polio vaccination, or incomplete
vaccination. (p. 1)
As a result, Mothers with a low educational level are more than likely not to get their children
completely vaccinated. It is imperative that nurses and healthcare professionals instruct all
mothers on how important vaccines are to help prevent illness in newborns and children.
Another factor that plays a role in vaccine hesitancy is race and ethnicity. Due to different
health care coverages, some families cannot afford to get vaccines for their children which leaves
many children under vaccinated. According to Lu, P., O'Halloran, A., Williams, W. W., Lindley,
M. C., Farall, S., & Bridges, C. B., (2015), “Vaccination coverage was significantly lower among
FACTORS INFLUENTING VACCINE HESITANCY 10
non-Hispanic blacks, Hispanics, and non-Hispanic Asians compared with non-Hispanic whites”
(p. 1). Having lower coverage makes families have more difficulty with getting their child
completely vaccinated, or even if they have more than one child getting all children completely
vaccinated can be expensive. This makes families stray away from getting their children
vaccinated. With low coverage also comes low income. Low income also contributes to children
not being vaccinated due to the cost of getting all vaccines for a child. Vaccines are expensive to
begin with but with low income, or only one source of income in some families, makes vaccines
hard to afford. Families cannot afford health insurance or choose not to have health insurance
due to saving money or do not believe they need it. Not having health insurance due to low
income and no health care can make out of pocket cost for child vaccines even more expensive
this causes families not to get their children vaccinated which can lead to mortality that could
have prevented.
In short, an article from the World Health Organization (WHO) about measles helps show
why not getting completely vaccinated can lead to death in children. “In 2015, there were
134,200 measles deaths globally – about 367 deaths every day or 15 deaths every hour.”(World
Health Organization, 2017). Lastly, getting vaccinated can save a lot of children’s lives for
instance “During 2000-2015, measles vaccination prevented an estimated 20.3 million deaths
making measles vaccine one of the best buys in public health.”(World Health Organization,
2017). With low educational level, low income, and race/ethnicity makes getting children
vaccinated more difficult, but with programs and cheaper health care insurances. Families can
find a way to vaccinate their children and reduce the chance of mortality greatly.
FACTORS INFLUENTING VACCINE HESITANCY 11
Emotional Fears
Much information was found while reviewing literature regarding the various fears
that effect a parent’s decision to vaccinate or not vaccinate their child. These fears include
safety, side effects of vaccinations, development of autism, physiologic reactions and the use
of needles. Parents also fear that the vaccines recommended for their children may contain
harmful ingredients, harm the child’s immune system or even cause the disease it is made to
prevent. Even further they fear this resulting in suffering and/or death for their child. Yet
another fear that arises comes from the fact that parents may not trust pharmaceutical
companies. As a result of these fears, parents may choose not to vaccinate their children,
increasing the susceptibility of their children to a Vaccine Preventable Disease (VPD). This
choice can also have effects on the larger community, as it increases the number of
susceptible individuals. This explains the increasing number of outbreaks spreading in largely
unvaccinated communities.
Fears of vaccines are nothing new. They can be traced back to the 18 th century when
smallpox tore through colonial North America. When smallpox was introduced to a colonial
port city, up to 60% of the residents would become ill and an estimated 25% would die
(Boom, J.A., Cunningham, R. M., & Springer, J, 2014, p.3). Regarding inoculation for this
disease, people were hesitant on rubbing material from a smallpox sore into a wound, a
Still today there are modern day fears towards vaccines that date all the way back to
1955 when the Cutter Incident occurred. After this, the documentary, “DTP: Vaccine
Roulette” was released in the 1980’s. The Cutter Incident refers to when polio vaccines were
distributed to children and were not fully inactivated. This resulted in a significant amount of
FACTORS INFLUENTING VACCINE HESITANCY 12
morbidity and mortality for these innocent children. The documentary mentioned above,
further created fears about the DTP vaccine and is actually the reason the National Vaccine
Information Center was established (Boom et al., 2014, p.2). This information center further
increased parental safety concerns toward vaccinations when they published a controversial
paper suggesting the link between vaccines and autism (Boom et al., 2014, p.2). Although the
document had been retracted and many of its author’s findings were discovered as false, more
people joined the anti-vaccine movement. Still today many people from all parts of the
pediatricians need to be the ones who educate on the facts and falsify rumors. Parents who
trust that their child’s welfare is the primary motivation of their pediatrician will be most
about both the benefits and risks of vaccines they want their pediatric patients to be
administered. Also, since many parents do not understand the severity of these diseases, they
are encouraged to remind them that effective treatments are not realistic once the disease has
the parent’s fears. For example, a physician should approach a concerned parent differently
The HPV vaccine continues to have the lowest initiation rate of any other routinely
recommended vaccines in the United States, despite being proven as one of the most
effective. Many parents have great fear that the HPV vaccine may not be safe or effective.
FACTORS INFLUENTING VACCINE HESITANCY 13
There is a large amount of evidence that pediatricians can present chair of the lower fears of
patients and parents and improve HPV vaccination rates. For example, syncope is the most
common safety concern and discomfort is the most common adverse effect with this vaccine.
Other common fears include failure of the ovaries, adverse allergies, seizures, stroke and
even death ( Brown, B., Gabra, M. I., & Pellman, H., 2017). Yet, surveillance after
administrations has not displayed an increased risk of any of those outcomes after being
vaccinated for HPV. In addition, the most common reason for refusal of the HPV vaccine is
the need for more education and answers regarding the vaccination. (Brown et al., 2017).
Another common situation occurs when parents start their child on the HPV vaccination
series, but do not finish it completely. A study with the purpose of discovering the reasons
why parents do not finish HPV series found that the main reason is because parents are not
being notified to make appointments for their child’s next administration (Apte, 2015). The
discussion of this study includes that health care providers and parents need to better their
communication, specifically suggesting the use of a reminder system. It also states that the
results of the study support the importance of public education about the vaccine.
The very common fear that parents and their children have, which results in not being
vaccinated, includes the fear of needles and/or size of the needle. Within a research study that
examined the prevalence needle fears, interventions were applied to the participants that
analgesic interventions during injections (Ipp, M. , Jamal, A., Katz, J., Parikh, Ch., Smart, S.,
Sovran, J., Stephens, D., Taddio, A., Thivakaran, S., 2012). Highlights of the study include:
needle fear and impact on vaccine adherence. Needle fear was present in 2/3 of
FACTORS INFLUENTING VACCINE HESITANCY 14
children and 1/4 of adults. Vaccine non-adherence due to needle fear occurred in 1/12
Conclusion
As the majority of parents report, physicians and nurses are one of the most trusted
sources of information when discussing childhood vaccines. Nurses must have the knowledge to
discuss the benefits of immunizations, as well as the risks of delaying and stopping vaccinations.
They must address parental apprehensions towards vaccines in an understanding manner and
offer educational information to help them make a more informed decision. Parents may also
benefit from being provided customized vaccination educational material that corresponds with
Another suggestion to quell vaccine hesitancy is a reminder system that could be put in
place by family physicians and local public health offices. This could serve as a prompt for
parents to visit their physician to receive their child’s vaccination or discuss any anxieties they
home visits for those that are impeded by travel restrictions or financial limitations. In regard to
social influences, it is important that social networking sites be further examined since they are
Vaccines save countless lives each year and remain one of the most effective way to
prevent health disparities. Although many illnesses are unavoidable, others can be serious and
confidence and acceptance with their patients. Nurses must make the most of their opportunities
as educators while working within the healthcare system. Studies have shown that while
vaccination statistics have remained steady over the last ten years, one in five parents still has
FACTORS INFLUENTING VACCINE HESITANCY 15
concerns regarding childhood immunizations. Since all of the factors above are contributing to
References
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