Elsevier

Vaccine

Volume 28, Issue 26, 11 June 2010, Pages 4235-4248
Vaccine

Review
Factors underlying parental decisions about combination childhood vaccinations including MMR: A systematic review

https://doi.org/10.1016/j.vaccine.2010.04.052Get rights and content

Abstract

Suboptimal childhood vaccination uptake results in disease outbreaks, and in developed countries is largely attributable to parental choice. To inform evidence-based interventions, we conducted a systematic review of factors underlying parental vaccination decisions. Thirty-one studies were reviewed. Outcomes and methods are disparate, which limits synthesis; however parents are consistently shown to act in line with their attitudes to combination childhood vaccinations. Vaccine-declining parents believe that vaccines are unsafe and ineffective and that the diseases they are given to prevent are mild and uncommon; they mistrust their health professionals, Government and officially-endorsed vaccine research but trust media and non-official information sources and resent perceived pressure to risk their own child's safety for public health benefit. Interventions should focus on detailed decision mechanisms including disease-related anticipated regret and perception of anecdotal information as statistically representative. Self-reported vaccine uptake, retrospective attitude assessment and unrepresentative samples limit the reliability of reviewed data – methodological improvements are required in this area.

Introduction

Parental choice to decline childhood vaccinations is recognised as an important factor in suboptimal uptake [1], [2], [3], [4]. In recent large UK studies where unimmunised cases made up on average 5% of all children studied, three quarters of parents whose children were unimmunised with the measles, mumps and rubella (MMR) vaccine [1] and almost half of parents whose children were unimmunised with the primary schedule of vaccines (at that time diphtheria, tetanus, pertussis and Hib combined, oral polio and meningitis C) [4] said they had made a conscious decision to reject the vaccine. Such decisions are rooted in complex belief structures, and by understanding and modifying these beliefs it may be possible to influence decisions, thereby improving uptake. To this end, many studies have examined parental beliefs about childhood vaccinations [3], [5], [6], [7]. Studies have been conducted in numerous countries, with various vaccines, and differing vaccination policies and vaccine-preventable disease prevalence. Further, these studies span several decades, taking in multiple vaccine scares and disease outbreaks.

To impact significantly on the conduct of policymakers, parents, practitioners and researchers, this existing large body of evidence must be rendered accessible using objective methods. There are no up-to-date, systematic reviews of parental beliefs about and attitudes toward childhood vaccination suitable to inform local or national interventions to improve vaccine uptake. Narrative reviews identify a number of factors which may influence vaccine uptake, including practical barriers to and facilitators of uptake, media and lay representations of disease and vaccination, and trust in healthcare providers [3], [5], [8], [9]. Three systematic reviews identify commonalities in the evidence base which generally support the conclusions of narrative syntheses, however their methodologies and scopes limit their suitability to inform current policy and practice [6], [10], [11]. The most recent of these [6] reports research on parental beliefs only as a small component, and comprises both empirical and anecdotal evidence about the views of parents and health professionals. A slightly older review [10] considers only qualitative studies reporting barriers to uptake of the entire vaccine schedule. These studies may not be generalisable to a specific vaccine, because evidence suggests that uptake varies by vaccine [12], therefore that parents may not make decisions about the entire vaccine schedule, but rather about individual vaccines. The oldest review [11] used Bayesian meta-analysis to calculate the influence of various factors on vaccine uptake, but incorporated only studies published to July 1999 – predating the MMR controversy which took hold in the UK around the turn of the century [13].

This review aims to identify and synthesise evidence on which factors underpin decisions about combination vaccines (which protect against more than one disease in a single shot). Combination vaccines have been selected because it is “inevitable” [14] that more vaccines will be offered in combination rather than separately in the future [15], [16], and because combination-specific concerns may play a key role in parents’ decisions and behaviour (as indicated by some parents’ willingness to pay for separate measles, mumps and rubella vaccines) but the extent to which these concerns are addressed in the literature is unclear.

Section snippets

Search strategy and selection criteria

MedLine (including in-process & other non-indexed citations), PsycINFO, EMBASE, Maternity and Infant Care and International Bibliography of the Social Sciences were searched through Ovid. Reference lists of seminal articles and contents lists of appropriate journals were scrutinised, and unpublished literature and non-journal publications from relevant agencies were sought.

Keywords and MeSH terms were generated around four facets dictated by the review question: parent, decision, child and

Characteristics of studies

Two-thirds of included studies (including all the qualitative studies) were conducted in the UK and Eire. A higher proportion of UK/Eire studies than studies from elsewhere reported on healthcare system/Government factors, non-official sources of information, decision-making and individual differences. There is little evidence of any systematic differences in findings between UK/Eire studies and studies from elsewhere, except on some demographic factors – parental education, income, family size

Discussion

This review identifies and synthesises quantitative and qualitative evidence on the factors underlying parental decisions about combination childhood vaccines. Quantitative data demonstrate that generally parents making vaccination decisions act in accordance with their attitudes and beliefs about vaccine-related factors (Fig. 1). However, on some factors vaccine-acceptors and decliners did not differ. Accordingly, the qualitative data reveal that, whilst vaccine-acceptors generally hold

Acknowledgements

This review was funded by a Health Protection Agency Ph.D. studentship in Behavioural Science. The funder had no role in the conduct of the review or the decision to submit the paper for publication. The Clinical Safety Research Unit is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust which is funded by the National Institute of Health Research.

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