Factors That Influence Parents' and Informal Caregivers' Views and Practices Regarding Routine Childhood Vaccination: A Qualitative Evidence Synthesis (Review)

"Currently, there is a large global focus on the demand side of vaccination."

Understanding parents' and informal caregivers' reasons for their vaccination views and practices could help inform the development of interventions to promote acceptance and uptake of vaccines that are better aligned with people's norms, views, expectations, and concerns, thereby potentially enhancing vaccines' acceptability and effectiveness. To that end, this Cochrane synthesis of qualitative evidence, produced by Cochrane Effective Practice and Organisation of Care (EPOC), explores literature on the factors that influence parents' views and practices around routine childhood vaccines. It complements other Cochrane Reviews assessing the effect of strategies to improve the uptake of childhood vaccines (see, e.g., Related Summaries, below).

A search of studies published from 1974 to June 3 2020 led the researchers to identify 145 relevant studies; they analysed the results from 27 of them. Studies were conducted in Africa, the Americas, South-East Asia, Europe, and the Western Pacific, in both urban and rural locations, within high-, middle-, and low-income settings. People in the study were parents or carers who were responsible for deciding whether a child should be vaccinated.

An overall finding is that many factors influence parents’ vaccination views and practices, including those related to individual perceptions, social relationships, and the wider context in which parents live. When parents make decisions about vaccination for their children, they are often communicating not just what they think about vaccines, but also who they are, what they value, and with whom they identify.

The findings are broken down into 19 main findings (with GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) assessment for each), organised into 4 main themes:

1. Ideas and practices surrounding (child) health and illness:
   • Religious beliefs: Some parents were less accepting of childhood vaccination due to the religious beliefs they held and the view that illness can only be prevented by divine providence. (Low confidence)
   • The "fragile" infant: An understanding of infants as weak and vulnerable, and their immune systems as still in a state of development, was common amongst parents across diverse settings, contexts, and population groups. This perception was associated with both reduced and increased acceptance of childhood vaccination. (High confidence)
   • Primacy of "nature" and "the natural": Some parents, predominantly from high-income countries (HICs), conceive of many biomedical interventions, including vaccination, as unnatural intrusions that are unnecessary or harmful. Various parents who held this view also engaged in "natural" health-promoting activities, which for them further negated the need for vaccination. (High confidence)
   • Individualised health, immunity, and vaccine-response trajectories: Many parents, predominantly from HICs, held a view that children possess unique bodies and immune systems, and therefore individual vaccine needs and vulnerabilities. If the risks were seen to outweigh the benefits for their particular child, then these parents tended to be less accepting of childhood vaccination. (High confidence)
   • Parental expertise. Many parents from HICs held a view of themselves as possessing the best understanding of their child's health strengths and vulnerabilities. They in turn considered themselves best placed to judge their child's vaccination needs and risks. (Moderate confidence)
   • Personal choice and responsibility: Many parents, predominantly from HICs, perceived healthcare decision-making, including vaccination, to be a matter of personal, not collective, responsibility and choice. These parents in turn tended to be less accepting of vaccination for their children. (High confidence)
2. Social communities and networks:
   • Social networks shaping vaccination ideas and practices across diverse settings, contexts, and population groups: These networks included relatives, peers, neighbours, and additional significant others in the community. The views and practices of other parents, and particularly other mothers, were especially influential. (High confidence)
   • Vaccination ideas and practices shaping social networks: Shared vaccination ideas and practices were a powerful force in building social relations and ties, particularly for parents who are less accepting of vaccination. In these cases, parents may be afforded access to various types of social resources, in turn potentially reinforcing both their group affiliation and vaccination views and practices. (Moderate confidence)
3. Political events, relations, and processes:
   • Distrust in the institutions or systems implicated with vaccination: The reasons for distrust government, the pharmaceutical industry, and science were complex and contextually situated, embedded in political events, relations, and processes within specific times and places. (Moderate confidence)
   • Generalised decline in trust of authority and expert systems: For some parents, distrust of the institutions or systems implicated with vaccination may be part and parcel of a more generalised contemporary trend of decreasing trust in authorities and expert systems. (Low confidence)
   • Agendas and interests underpinning the expert systems implicated with vaccination: Many parents were particularly concerned about the economic interests of these systems, and especially the economic interests of the pharmaceutical industry, which they perceived to be negatively influencing vaccination programmes. (Moderate confidence)
   • Current and past controversies: Some parents' distrust was linked to particular "scandals" or "controversies" related to vaccination specifically or health-related issues more broadly. The occurrence of such scandals, and the manner in which they were perceived to have been handled, caused some parents to feel misled by authorities and to question their legitimacy in protecting the public's health. (Low confidence)
   • Marginalisation, inadequate public services, and misalignment between parents' own priorities and those of the state: These experiences undermined trustful and benevolent state-citizen relations, leading many parents to distrust government and government-sponsored programmes, including vaccination. (Moderate confidence)
4. Access-supply-demand interactions:
   • Socioeconomic challenges in accessing vaccination services (e.g., geography and transport, childcare constraints, and family economics and household work pressures).(High confidence)
   • Undesirable features of vaccination services and delivery logistics (e.g., resource constraints that affect vaccine supply and costs and health facility waiting times, and constraining organisational procedures). (Moderate confidence)
   • Vaccination as a social event: For some parents, the social nature of vaccination services was a negative experience, whereby they felt judged by, disapproved of by, or alienated from others. This potentially demotivated attendance of childhood vaccination services. (Low confidence)
   • Interactions with frontline healthcare workers: Some parents were less accepting of vaccination due to mistreatment from healthcare workers, and when they felt the vaccination information provided to them was simplistic and unbalanced. In contrast, some parents were more accepting of vaccination due to positive engagements with healthcare workers, whereby they felt supported, listened to and respected, and whereby healthcare workers shared balanced information and personal stories about themselves as parents. (High confidence)
   • Neoliberal logic: Many parents, particularly from HICs, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as conflicting with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. (Moderate confidence)
   • Social exclusion: Some parents, particularly from low- and middle-income countries (LMICs), were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and dampen their motivation to seek public services that are of poor quality and/or difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. (Moderate confidence)

In conclusion, the review has revealed that "parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic." It has provided "a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting."

Editor's note: Accompanying this review is a 4-page implementation guide [PDF], prepared by Claire Glenton and Chris Cooper, Cochrane Norway/EPOC, September 2021. The questions and prompts presented here were informed by the review and may help ministries of health, programme managers, healthcare facilities, and other stakeholders to plan, implement, or manage childhood vaccination programmes.