Running Head: VACCINATION REFUSAL

Childhood Vaccination Refusal

Kyle Taylor
Bon Secours Memorial College of Nursing

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Abstract

Parents refusing to vaccinate their children are a growing problem worldwide. This practice not
only puts their children at risk for acquiring preventable disease, but it puts other vaccinated
children at risk as well. This paper analyzes five articles that question why parents refuse or
delay vaccinations for the children. Reasons for vaccine refusals are varied and numerous. Five
themes have been identified from the articles and analyzed. These themes are: side effects of
vaccines, schedule of immunizations, lack of perceived need for vaccinations, relationship with
the healthcare provider and the need of information regarding vaccinations. These themes were
then analyzed and discussed in detail. Many of the themes analyzed have interventions that can
be implemented to increase the childhood vaccination rate. Information gathered from this paper
can be used to as a basis for further studies and be used to implement interventions to refuse this
trend of childhood vaccination refusal.

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Childhood Vaccination Refusal

Vaccinations, especially for children, are a cheap and effective primary prevention
method. In the past fifty years, rates of disease infection have been slowed and some diseases
like smallpox have been eradicated. Vaccinations have also been found to be relatively risk free
for both adults and children. Vaccinations are an effective primary prevention that can both keep
adults and children healthy and disease free with minimal costs and risks. Even though these
factors are present, there has been a growing backlash against vaccinations. Celebrities have
spoken out against vaccinations and some parents are now questioning the need for vaccinations
for their children. While the majority of children still get vaccinated in todays time, a growing
number of parents are beginning to either delay or refuse to vaccinate their children.
The purpose of this integrative review is to understand the reasons why parents refuse to
vaccinate their children. By understanding the reasons why parents refuse or delay vaccinating
their children, steps can be implemented to reverse this trend. This is especially important
because vaccine refusal is a decision that can have far reaching effects. If enough children
remain unvaccinated, then herd immunity will suffer and vaccinated and unvaccinated children
could and would get sick. This can lead to an epidemic or a resurgence of previously eradicated
diseases. Furthermore, this is a problem that is affecting not just the United States; it is a
worldwide problem. While the number of parents who refuse to vaccinate their children is still
low, concerns about the growing number of vaccination refusals are becoming apparent.
Because of this, steps must be taken in order to begin to reverse this recent trend. The question
that needs to be answered is this: why do parents with children under twelve refuse to vaccinate
their children?

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The methodology used for this study was an integrative review strategy that outlined
performing a systematic search of at least two databases. Data from primary sources with
various methodologies was used to understand why parents refuse vaccinations and how to
combat this trend. The sources were then read, analyzed and compared in order to fully
understand the root problem. Conclusions were then drawn and then rechecked with the primary
sources.
A literature search was done with the PUBMEB and EBSCO databases. A very broad
search strategy with keywords was used. The keywords searched on these databases included
childhood vaccinations, parental hesitancy vaccinations, and vaccine refusals. The searches were
conducted during one session in September of 2014. Inclusion data included was: written in the
English language, article was under five years old, article was published in a peer reviewed
journal and the children in the study were under twelve years old. Exclusion criteria were review
articles. The abstracts were then read on a basis of the inclusion data. Five articles met the
inclusion data and the articles were then questioned, read and summarized.
The five studies that were analyzed include qualitative, mixed methods and quantitative
studies. Two of the studies were cross sectional descriptive studies, one was a phenomenology
study, one was a mixed method and the last one was a randomized control trial. The results of
the data were analyzed and displayed in a table. The data was also broken down into broad
themes on why there is a hesitancy or refusal of parents to vaccinate their children. Data was
also analyzed to find out rates of vaccine refusal and interventions needed to reverse vaccine
refusal.
The first factor analyzed was the rate of vaccine refusal. In 2009, 60.2% of parents
neither delayed nor refused a dose of any recommended vaccine (Smith et al., 2011). This data

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shows that a majority of parents do not hesitate to vaccinate their child. Approximately 25.8% of
parents delayed one or more recommended vaccine does, 8.2% refused one or more
recommended vaccine doses and 5.8% both delayed and refused recommended vaccine doses.
The analysis of the data reveals that while the majority of parents sill vaccinates their child, a
significant number of parents are either delaying vaccinations or refusing them outright.
Furthermore, among children that were not fully vaccinated by 24 months, the average number
of missed doses was 7.7 among children whose parents neither delayed nor refused, 6.3 among
children whose parents only delayed, 10.6 among children whose parents only refused and 9.7
among children whose parents had both delayed and reused at least one dose of vaccine.
Analysis of the data reveals that children whose parents refuse or refuse and delay vaccines miss
more doses that parents who do not refuse or delay any vaccinations.
After determining the rates of vaccine refusal, the data was then analyzed for reasons
why a parent would refuse vaccinations. The data was then categorized into broad themes. The
first theme analyzed was risk perception of vaccine side effects and side effects of vaccinations.
In one study, 53.5% of respondents were worried about vaccine side effects and the safety of
immunizations (Luthy et al., 2010). This response had a higher number of responses than any
other response showing that this concern is a big impediment to childhood vaccinations. This
theme was then explored into greater detail. In a qualitative study, participants answered that the
likelihood of negative consequences of vaccination is higher and the consequences are more
severe than getting the disease (Harmsen et al., 2013). These participants feel that vaccinations
pose much more risks than the diseases that they help to prevent. In this theme, a major
component that frightens the parents is the supposed link between vaccinations and autism.

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Parents fear a causal link between immunizations and autism (Luthy et al., 2010). This theme is
noted for eliciting especially strong feelings from the parents.
The second theme analyzed was the actual schedule of the immunizations. In one study,
20.9% of the parents responded that there was a concern that administering too many
immunizations at one time could overload their childs immune system (Luthy et al., 2013).
These parents are concerned that administering too many immunizations at the same time could
overload a childs immune system or damage the childs neurological system. This has been
shown to be a major obstacle to childhood immunizations. For example, parents who delayed
and refused vaccines were significantly more likely to say the reason for delaying and refusing
was because there were too many shots (Smith et al., 2011). This theme relates to the first theme
analyzed. Many of the parents were concerned about the vaccination schedule because of
concerns about autism and side effects. Many of the respondents indicated that if the
immunizations were not as close together, then they would be more likely to vaccinate their
children fully. For example, many of the parents believed that they could divert a childs
susceptibility to autism by adjusting the immunization schedule (Luthy et al., 2010). Adjusting
the immunization schedule would make many of the parents feel more comfortable receiving
vaccinations for their children.
The third theme analyzed was the lack of perceived need for vaccinations. In particular,
some of the respondents in one study listed some immunizations as unnecessary, i.e. varicella
vaccine (Luthy et al., 2010). A common response in many of the studies is that there was no
need for vaccinations. In particular, there was a view that there is an advantage to having a
disease so there is no need to vaccinate. For example, some participant cited the advantage of
life-long immunity in acquiring a disease and some participants believed a child would develop

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physically and/or mentally after getting a disease (Harmsen et al., 2013). The benefits perceived
of acquiring a disease made getting their children vaccinated unnecessary.
The fourth theme analyzed was the relationship to the healthcare provider. For example,
many parents who delayed and refused vaccines were significantly less likely to believe that they
had a good relationship with their childs health-care provider. Furthermore, these parents
believe that their medical professions in charge of vaccinations do not have their childs best
interests at heart (Smith et al, 2011). There is a correlation between trust in the healthcare
provider and vaccination rates for children. For example, in one study only 69% of parents who
delayed vaccines and 38% of parents who refused vaccines expressed a high level of trust in their
pediatricians advice on vaccines (Glanz et al., 2013). These parents do not trust that their
pediatrician or health care provider has the best interests of the child. Furthermore, parents have
expressed frustration with their healthcare provider for rushing through appointments and not
allowing enough time to adequately address their questions (Luthy et al., 2010). Some parents
believe that their health care provider is not providing adequate information regarding
vaccinations. Even if the parents feel like they have enough time to discuss vaccination with
their healthcare providers, some parents feel as if their pediatricians vaccine information was not
balanced. A majority of parents in one study reported that their pediatrician discussed the
benefits but not the risks of vaccinations (Glanz et al., 2013)
The fifth theme analyzed was need of information regarding vaccinations. In one study,
many of the participants mentioned that they did not receive enough information from the
National Institute of Public Health and the Environment (RIVM) about childhood vaccinations
(Harmsen et al., 2013). One participant noted that they only get a leaflet with a big piece of text
about vaccinations. Information needs as a whole are not being addressed concerning childhood

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vaccinations. For example, another article researched the effects of tailored information and
untailored information about vaccinations on vaccine adoption. This study found that providing
parents with information tailored to the individual parent leads to an increase in parents willing
to vaccinate their children against measles, mumps and rubella (MMR) (Gowda et al., 2013).
Conversely, using generalized, untailored information has a smaller success rate in vaccine
adoptions. Using a leaflet with a big piece of text, like the one a concerned parent noted, leads to
a smaller vaccine adoption rates and can led to questions about childhood vaccinations.
The reasons for childhood vaccination refusals or delays are varied. By far the biggest
reason noted by respondents in the studies was fears over the safety of vaccines. Several of the
studies used here list this reason as a major impediment to parents vaccinating their children.
More specifically, many parents have noted a link between autism and vaccination. Parents see a
link between vaccinations and developmental problems, like autism, with the current vaccination
schedule (Luthy et al., 2010). Delving deeper into this matter, parents have concerns about the
components of vaccines. The parents note the negative consequences of adjuvants in vaccines
like mercury and aluminum (Harmsen et al., 2013). Other preservatives and heavy metals were
also noted by parents to be present in vaccines and to give them concern. Thimersosal and other
preservatives proved to be a concern on brain development in children (Luthy et al, 2010).
Components of the vaccines and the perceived side effects of vaccines were enough for many
parents to question and refuse vaccinations.
Another factor noted in most of the studies was the actual vaccination schedule. As noted
earlier, many of the parents were concerned with vaccination side effects and autism, yet they
still saw the benefit of vaccinations. This made the parents try to balance their fears of autism
with immunization adherence. In order to combat this, many of the parents would delay or have

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vaccines given one at a time in their children (Luthy et. al., 2010). Parents had concerns that too
many vaccines at once could be detrimental to childrens health. They think that administering
many different viruses at the same time would be a huge attack on the immune system (Harmsen
et al., 2013). The studies imply that if the vaccination schedule was altered and vaccines were
not give so close together, many parent would opt to vaccinate their children.
Finally the themes of trust in their healthcare provider and lack of information available
seems to be a major impediment to childhood vaccination adherence. In every study used here,
either a lack of trust in the healthcare provider of a lack of trusted information was cited as a
reason to refuse vaccinations. One of the biggest concerns in this theme was a lack of balance in
the healthcare providers description of vaccines. The parents implied that the physicians are
either not educated on the risks of vaccines or they to not tell the parents the risks of vaccines
(Glanz et al., 2013). The parents are dissatisfied when the provider says there are no risks to
vaccinations. These parents either do not have a good relationship with their provider or do not
believe their provider is doing whats best for their child (Smith et al., 2011). Regarding the
healthcare provider and information about vaccines, many parents did not feel as though the
provider allotted enough time to give information on vaccines. The parents feel as though there
should be extra time to talk to parents about vaccines instead of just forcing the issue (Luthy et
al., 2010). This distrust in their provider incorporates the lack of information on the subject.
Parents want to feel as if their plan of care for their child is individualized (Luthy et al., 2010).
They want information delivered to them that is individualized. Many of the parents feel as if
they do not get enough information; they simply get what the provider deems as important
(Harmsen et al., 2013). Parents want information that is tailored to their situation instead of just
broad information on the subject. They want information that is applicable to their situation

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(Gowda et al., 2013). This lack of trust in their healthcare provider and the lack of unbiased
information can and does have a negative impact on vaccination adherence. If the parents do not
feel as if they are getting all of the information, then they will start to seek information from
other sources (Harmsen et al., 2013). These sources may not be trustworthy or they may be
biased against vaccines. Without a tailored approach that encompasses all of the information
about vaccines, the parents may find other sources that invalidates the use of vaccines. Vaccine
adoption rates may fall because of a healthcare provider not giving all of the information about
vaccines or the information not being comprehensive enough for the parent.
There are wide ranging implications from this review for the future regarding vaccination
hesitancy. Many of the reasons that parents refuse to vaccinate their children appear to be
reversible. Concerns about the additives and preservatives like mercury is the only reason that
cannot be combated by a health care provider. Lack of information seems to be the greatest
reason that parents do not vaccine their child. If health care providers give all the facts about
vaccinations, including side effects and risks, parents seem to be more likely to vaccinate their
children. There also needs to be a different approach in teaching parents about vaccinations.
Giving information that is uniform and not individualized seems to have a negative effect of
vaccination adoption. Tailoring information to the individual and the family is a way to increase
vaccinations and to get the right information to the parents. If the parents do not feel as though
they are getting all the information that they require, they are likely to seek the information from
other sources. These sources may be biased or outright wrong. Healthcare providers making
time for parents and answering all of their questions and giving them a full picture on
vaccinations would help to increase childhood vaccination rates.

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There were a few limitations to this review. For this topic, it was difficult to find truly
quantitative studies. Only one of the studies used was a randomized control study. The other
studies were either qualitative, mixed studies or was quantitative with a non-experimental design.
This implies that more information needs to be gathered for this subject and more studies needs
to be done. More quantitative studies that are truly randomized will give more information on
this subject. Another limitation present in two of the studies is the sample size. Seventy-nine
and eight six subjects is not a big enough sample to make generalized statements. In one study
in particular the authors not that the sample size is not large enough to be statistically significant.
Studies with a larger sample size are needed in order to make the data statistically significant.
There are many reasons why parents refuse to vaccinate their child. Concerns about the
side effects, concerns about autism, and a lack of information are the top reasons why parents say
they do not want to vaccinate their child. Many of these reasons, however, can be addressed. If
a healthcare provider remains unbiased and gives all the information about vaccines, adoption
rates seem as if they would go up. A new approach to teaching also has to be implemented. It is
not enough to give parents a CDC vaccine information sheet. Information has to be
individualized and tailored to the parents and the child. These interventions can be implemented
and vaccination rates can increase.

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References:

Glanz, J.M., Wagner, N.M., Narwaney, K.J., Shoup, J.A., McClure, D.L., McCormick, E.V. &
Daley, M.F. (2013). A mixed methods study of parental vaccine decision making and
parent-provider trust. Academic Pediatrics, 13(5): 481-488.
Gowda, C., Schaffer, S.E., Kopec, K., Markel, A. & Dempsey, A.F. (2013). A pilot study on the
effects of individually tailored education for MMR vaccine-hesitant parents on MMR
vaccination intention. Human Vaccines & Immunotherapeutics, 9(2): 437-445. Doi:
10.416/hv.22821.
Harmsen, I.A., Mollema, L., Ruiter, R.A.C., Paulussen, T.G.W., de Melker, H.E. & Kok, G.
(2013). Why parents refuse childhood vaccination: a qualitative study using online focus
groups. BMC Public Health, 13. Doi: 10.1186/1471-2458-13-1183.
Luthy, K.E., Beckstrand, R.L. & Callister, L.C. (2010). Parental hesitation in immunizing
children in utah. Public Health Nursing, 27(1): 25-31. Doi 10.1111/j.15251446.2009.00823.x
Smith, P.J., Humiston, S.G., Marcuse, E.K., Zhao, Z., Dorell, C.G. & Hibbs, B. (2011). Parental
delay or refusal of vaccine doses, childhood vaccination coverage at 24 months of age,
and the health belief model. Public Health Reports, 126: 135-145.