IN PRACTICE
COCHRANE CORNER

 

Factors that influence parental and caregiver acceptance of routine childhood vaccination: Summary of a qualitative evidence synthesis

 

 

S Cooper^{I, II, III}; B-M Schmidt^IV; A Swartz^{II, V}; C J Colvin^{II, VI, VII}; N Leon^{VII, VIII}; E Z Sambala^IX; A Jaca^I; N Gloeck^XIV; N Pillay^{X, XI}; T Kredo^{I, II, III, XII}; C Wiysonge^{I, II, III, XIII}

^IPhD; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
^IIPhD; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
^IIIPhD; Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
^IVPhD; School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
^VPhD; Department of Psychosocial and Psychoanalytic Studies, University of Essex, Colchester, UK
^VIPhD; Department of Public Health Sciences, University of Virginia, Charlottesville, USA
^VIIPhD; Department of Epidemiology, School of Public Health, Brown University, Providence, USA
^VIIIPhD; Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
^IXPhD; School of Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
^XPhD; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^XIPhD; Sarraounia Public Health Trust, Johannesburg, South Africa
^XIIPhD; Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
^XIIIPhD; HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
^XIVMSc; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa

Correspondence

 

 

---

ABSTRACT

We summarise a Cochrane review of qualitative evidence that explored parents' views and practices around routine childhood vaccination, and provide implications for research and practice that are relevant to the South African (SA) context. Many public health interventions to encourage vaccination are informed by an assumption that vaccine hesitancy is due to a lack of knowledge or irrational forms of thinking. The findings from this review suggest that childhood vaccination views and practices are complex social processes that are shaped by multiple factors and carry a variety of meanings. As such, we suggest that biomedical approaches must be supplemented by more nuanced and sociopolitically informed strategies for enhancing and sustaining childhood vaccination practices in SA.

---

 

 

We summarise a Cochrane review of qualitative evidence that explored parents' views and practices around routine childhood vaccination,^[1] and provide implications for research and practice that are relevant to the South African (SA) context.

Immunisation is one of the most effective healthcare interventions to prevent serious illnesses and death in young children.^[2] Yet in SA^[3,4] and elsewhere,^[5] there are parents who question vaccines, seek alternative vaccination schedules and decide to delay or refuse vaccination for their children. Our understanding of the nature and drivers of childhood vaccination hesitancy is still limited.^[6,7]

 

Objectives

The review sought to synthesise qualitative studies exploring parents' views and practices around routine childhood vaccination, and to develop a conceptual understanding of the factors that reduce parental acceptance of routine childhood vaccination.

 

Methods

A comprehensive search conducted up to June 2020, and subsequent article screening, produced 145 eligible studies, of which 27 were purposively sampled for inclusion in the synthesis. The studies were conducted in Africa, the Americas, South-East Asia, Europe and the Western Pacific, and included urban and rural locations, as well as high-, middle- and low-income settings. A meta-ethnographic approach was employed for data extraction and synthesis. Methodological limitations were assessed with an adaptation of the Critical Appraisal Skills Programme (CASP) for Qualitative Studies assessment tool. Confidence in the review findings was evaluated using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach.

 

Results

Parents' views and practices around routine childhood vaccination were found to be influenced by multiple factors and to carry a variety of meanings - social, political, economic, ideological and moral as well as biological meanings. For example, many parents' vaccination views and practices were found to be shaped by their broader worldviews surrounding health and illness, by the vaccination ideas and practices of their social networks, by wider political issues and relations of power and, in particular, the impact these have on parents' trust (or distrust) in those associated with vaccination programmes, and by parents' access to and experiences of vaccination services and their frontline healthcare workers.

Based on the findings, the review authors 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, understand health and healthcare decisions to be matters of individual risk, choice and responsibility. Parents, across the spectrum of vaccination attitudes, may hold this worldview. Yet for some parents, this perspective is experienced as in conflict with vaccination promotion messages, which emphasise population-level risk, community health and shared responsibility for public health. This perceived tension may lead some parents to be hesitant towards vaccination for their children.

The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, may be less accepting of childhood vaccination owing to their experiences of social exclusion. Exclusion can take many different forms -economic, political and cultural, among many others. These different dimensions can lay the foundation for distrust, alienation, resentment and demotivation. This may, in turn, lead parents who are socially excluded to be hesitant towards vaccination for their children (i) because they distrust vaccines and those delivering them; (ii) as a form of resistance or a mechanism to bring about change; or (iii) owing to the time, costs (including opportunity costs) and distress it creates.

 

Conclusions

The review findings reveal that childhood vaccination views and practices are complex social processes, deeply embedded in the social worlds in which people live. This, in turn, suggests that childhood vaccine hesitancy is not a single problem; the way it manifests and why it occurs varies considerably across place, populations, time and even vaccines.

The diverse and socially dependent nature of childhood vaccine hesitancy means that no single and one-size-fits-all strategy is likely to address it. Rather, multi-component approaches are needed that are tailored to local sociopolitical contexts and target the specific concerns and meaning systems in those contexts.

The review identified only two studies conducted in SA. More qualitative research on this topic in the country is therefore needed so that appropriately targeted and tailored interventions can be developed.

Many public health interventions to encourage vaccination are informed by an assumption that vaccine hesitancy is due to a lack of knowledge or irrational forms of thinking ('knowledge-deficit' approach).^[7,8] They therefore attempt to address this gap through education and risk communication strategies. The findings from this review suggest that a more nuanced and less biomedical approach may be needed. Such an approach involves understanding and empathising with parents' social struggles and meaning systems, and the particular concerns these may give rise to.^[9] It includes appreciating that parents' values and priorities do not always align with the forms of rationality that underlie vaccination programmes. It entails recognising that parents' concerns about vaccines do not only have negative connotations, but are sometimes also about a striving for, or desiring, something positive for their children and themselves.^[10] These include, for example, a desire to protect their own child's health, to be part of healthcare decision-making, to belong and feel included among peers, to feel confident that expert systems have their best interests at heart, to have their own priorities recognised and to have their basic needs met. Such an approach means moving away from attempting to 'change attitudes' through one-way information delivery. Rather, it involves developing dialogue-based approaches that prime for nuance, encourage respectful and bridge-building discussions and find ways to build on the potential positive dimensions of parental concerns.^[8,10-12] It also entails encouraging critical thinking and engagement with scientific evidence and healthcare systems in order to foster meaningful communication and health literacy. SA has a rich history of community engagement and mobilisation through years of HIV advocacy and treatment literacy that could be drawn upon in this regard.^[13] Ultimately, such an approach is unlikely to translate into simple, 'quick-fix' interventions. Yet its potential to foster and sustain acceptance of childhood vaccination in SA makes it worth the trouble.

Declaration. None.

Acknowledgements. Cochrane Corners are co-ordinated from Cochrane South Africa at the SA Medical Research Council (SAMRC), but the views expressed in this article are those of the authors and do not necessarily reflect the views or policies of Cochrane or the SAMRC.

Author contributions. The manuscript was conceived by SC. SC wrote the first draft of the manuscript; SC and NP wrote the first draft of the 'Conclusions' section. All authors contributed to versions of the manuscript and approved the final draft.

Funding. This research has received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Conflicts of interest. None.

 

References

1. Cooper S, Schmidt BM, Sambala EZ, et al. Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: A qualitative evidence synthesis. Cochrane Database Syst Rev 2021;10:CD013265. https://doi.org/10.1002/14651858.CD013265.pub2        [ Links ]

2. Centers for Disease Control and Prevention. Ten great public health achievements - United States, 1900-1999. Morb Mortal Weekly Rep 1999;48(12):241-243. https://doi.org/10.1001/jama.281.16.1481        [ Links ]

3. Wiysonge CS, Ngcobo NJ, Jeena PM, et al. Advances in childhood immunisation in South Africa: Where to now? Programme managers' views and evidence from systematic reviews. BMC Pub Health 2012;12:578. https://doi.org/10.1186/1471-2458-12-578        [ Links ]

4. Oduwole EO, Laurenzi CA, Mahomed H, Wiysonge CS. Enhancing routine childhood vaccination uptake in the Cape Metropolitan District, South Africa: Perspectives and recommendations from point-of-care vaccinators. Vaccines 2022;10(3):453. https://doi.org/10.3390/vaccines10030453        [ Links ]

5. Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007 -2012. Vaccine 2014;32(19):2150-2159. https://doi.org/10.1016/j.vaccine.2014.01.081        [ Links ]

6. World Health Organization Strategic Advisory Group of Experts on Immunisation. Assessment report of the Global Vaccine Action Plan. Geneva: WHO, 2018. http://www.who.int/immunization/sage/meetings/2018/october/2_Draft2018GVAP_Ass_Rep.pdf?ua=1 (accessed 1 November 2019).         [ Links ]

7. Cooper S, Okeibunor JC, Wiyeh A, Wiysonge CS. Knowledge advances and gaps on the demand side of vaccination. Lancet Infect Dis 2019;19(1):13-15. https://doi.org/10.1016/S1473-3099(18)30733-3        [ Links ]

8. Dube E, Gagnon D, MacDonald N, Bocquier A, Peretti-Watel P, Verger P. Underlying factors impacting vaccine hesitancy in high income countries: A review of qualitative studies. Expert Rev Vaccines 2018;17(11):989-1004. https://doi.org/10.1080/14760584.2018.1541406        [ Links ]

9. Joska JA, Rabie S, Sibeko G. Changing minds: A behavioural approach to vaccine hesitancy. S Afr Med J 2022;112(2):66-67. http://doi.org/10.7196/SAMJ.2022.v112i2.16301        [ Links ]

10. Leach M, Fairhead J. Vaccine Anxieties - Global Science, Child Health and Society. London: Earthscan, 2007.         [ Links ]

11. Attwell K. The politics of picking: Selective vaccinators and population-level policy. SSM Popul Health 2018;14(7)100342. https://doi.org/10.1016/j.ssmph.2018.100342        [ Links ]

12. Sobo EJ. Social cultivation of vaccine refusal and delay among Waldorf (Steiner) school parents. Med Anthropol Q 2015;29(3):381-399. https://doi.org/10.1111/maq.12214        [ Links ]

13. Heywood M. South Africa's Treatment Action Campaign: Combining law and social mobilisation to realise the right to health. J Human Rights 2009;1:14-36. https://doi.org/10.1093/jhuman/hun006        [ Links ]

 

 

Correspondence:
S Cooper
sara.cooper@mrc.ac.za

Accepted 12 August 2022