Running Head: FACTORS INFLUENCING VACCINE HESITANCY 1

Factors Influencing Vaccine Hesitancy Among Parents

Emily Eckman, Kirstie Lewis, Alex Rich, Amanda Rupp, Michael Sheridan

04/03/2017

NURS 3749: Nursing Research

Dr. Valerie O’Dell

FACTORS INFLUENTING VACCINE HESITANCY 2

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

supporting an increase in parental vaccine hesitancy regarding certain immunizations, as well as

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

Childhood Vaccine Hesitancy: Influential Factors Affecting Parents

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.

(2016), vaccine hesitancy is defined as “a spectrum of behavioral responses including refusal,

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

childhood vaccine hesitancy?

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

well as effects on the nursing field and healthcare.

FACTORS INFLUENTING VACCINE HESITANCY 4

Healthy People 2020

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.,

Dietz, V., 2016).

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

Alabama, North Carolina, Arkansas, New Mexico, Oklahoma, and Wyoming.

Variance of Vaccine Attitudes

As specified by a 2009 HealthStyles survey conducted on parents with children under 6

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

percentage rose to 50% in the same study.

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

identified in 2015, resulting in a startling 159 cases from 18 states.

Inaccurate perceptions of their child’s susceptibility to illness combined with attitudes of

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.

Healthcare and Nursing Implications

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-

vaccine advocates around the world continue to combat vaccine hesitancy.

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

survey were, “My doctor(s) recommendation affected my decision whether to vaccinate my

children for influenza” and “My nurse(s) recommendation affected my decision whether to

vaccinate my children for influenza” (p. 37).

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

friends telling them exaggerated ‘horror stories’ (p. 4).

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

difference in amounts of sources supporting and demonizing childhood vaccinations. Around

FACTORS INFLUENTING VACCINE HESITANCY 8

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

likely to remember reports of adverse reactions to vaccinations as compared to positive vaccine

administration experiences (Chen et al., 2011, p. 36).

FACTORS INFLUENTING VACCINE HESITANCY 9

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

polio vaccination, or incomplete vaccination. Further, unempowered women also had

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

procedure called variolation in 1726 (Boom et al., 2014, p.3).

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

worlds believe and promote these beliefs, including celebrities.

Additionally, as previously mentioned in this literature review, physician persuasion is

the most influential approach to vaccine-hesitant parents. In regards to fearing vaccinations,

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

likely to consider vaccinations (Diekema, D., 2012). In order to maintain a trusting

relationship with parents, it is recommended that physicians provide accurate information

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

developed. Effective communication with parents requires the physician’s understanding of

the parent’s fears. For example, a physician should approach a concerned parent differently

than a parent who is vaccine confident. (Diekema, D., 2012).

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

focused on improving education about vaccines, access to vaccinations and recommending

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:

1907 children and parents were surveyed to determine prevalence of self-reported

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

children and adults (Ipp et al., 2012)

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

each individual patient’s needs.

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

may be experiencing. Rural communities could incorporate a transportation system or offer

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

increasingly being used as informational sources.

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

often preventable. It is of utmost importance for healthcare professionals to cultivate vaccination

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

growing vaccine hesitancy, research and progressive changes need to continue.

FACTORS INFLUENTING VACCINE HESITANCY 16

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