‘Hesitant compliers’: Qualitative analysis of concerned fully-vaccinating parents

Abstract

Objective

Some parents are hesitant about vaccines and yet still vaccinate their children. Vaccine behaviours are not fixed and parents who are concerned but nonetheless adherent to standard schedules could switch to an unconventional schedule, delaying or cherry-picking vaccines. There is a need to better understand vaccine hesitancy in specific contexts, acknowledging cultural and geographical variation, to ensure interventions targeting hesitancy are well directed and received.

Methods

To identify the behaviours, knowledge and attitudes of ‘hesitant compliers’ in Perth, Western Australia, nine one-on-one in-depth interviews were conducted with vaccinating parents of children (<5 years) who were identified as being hesitant. Interview transcripts were analysed qualitatively and themes developed inductively, following a constructivist paradigm.

Results

Parents saw vaccination as important for themselves and their community, despite their limited knowledge of vaccine preventable diseases. Parents reported concerns about potential side effects, and worried about the safety of the measles-mumps-rubella (MMR) and seasonal influenza vaccines. Concerned about the role of anti-vaccination information in the community, some sought to isolate themselves from parents who did not vaccinate, although others were concerned that this could entrench non-vaccinators’ behaviours. Parents’ views were all underlaid by two pivotal ‘vaccine-related events’ that had occurred in the community: the severe injury of a baby from seasonal influenza vaccination in 2010, and the death of a baby from whooping cough in 2015.

Conclusions

Parents interpreted pivotal vaccine-related events in the community as requiring them to take personal responsibility for vaccine decisions. Their reports of continued vaccine fears (evident in international studies in recent decades) demonstrate that vaccine scares have long lasting effects. With vaccine rates high and stable, current strategies appear to be have little impact on addressing parental vaccine concerns. Further research is required to determine the prevalence of hesitancy amongst vaccinating parents and identify critical points for intervention.

Introduction

Childhood vaccination provides direct protection while also helping to maintain protection against disease across populations through community immunity [1]. Although most people accept vaccination as necessary, it may cause concern for varied religious, safety or political reasons [2]. In the last decades, community concern about vaccination has grown internationally, with debates about its safety [3] and movements against vaccination maintaining traction in the digital age [4]. This is occurring despite efforts of healthcare providers and policymakers to address parental anxieties both in the clinic and the community, with recent reviews finding a lack of evidence for successful interventions in either setting [5], [6]. Parental perceptions lie along a spectrum [7] with around one quarter of parents categorised as ‘vaccine hesitant’ in international studies [8]. Given that vaccine uptake internationally is high, a significant proportion of parents are accepting all vaccinations for their children despite unease about the vaccination process. [9], [10].

The hesitancy experienced by individuals regarding vaccination can develop over time, and parents can change their minds about vaccinating. A US study of 228 postpartum mothers found that while 29% worried about vaccinating their infants for reasons like safety, poor efficacy and mistrust, 96% nonetheless planned to accept recommended vaccinations [11]. Another US study found that one third of parents currently following alternative vaccine schedules had previously adhered to the standard schedule [12]. This suggests that vaccine behaviours are not fixed, and parents who are concerned but nonetheless adherent to standard schedules could switch to an unconventional schedule, delaying or cherry-picking vaccines. Consequently, these parents constitute an important target group for health professionals and policymakers seeking to maintain high and stable vaccination coverage rates.

Accordingly, there is a need to better understand vaccine hesitancy in specific contexts, acknowledging cultural and geographical variation, to ensure interventions targeting hesitancy are well directed and received appropriately. This exploratory study fills a research gap with regards to qualitative studies exploring parental vaccine hesitancy in Australia; we only know of one other recent published study [13]. In seeking to provide a better understanding of the cohort of parents who vaccinate despite concerns, we focused on the behaviour, knowledge and attitudes of parents who self-reported compliance with the Australian vaccine schedule despite expressing moderate concerns about childhood vaccinations – so called ‘hesitant compliers’[14]. We conducted this study in Perth, Western Australia (WA), which had recently been impacted upon by two pivotal events – the injury of a baby from seasonal influenza vaccination, and the death of a baby from pertussis disease (whooping cough). At the time of this study, vaccination in Australia was not compulsory but was linked to federal government financial incentives. In Australia, there are seven time points for vaccine delivery from birth to four years, plus an annual seasonal influenza vaccine. The latter is funded in Western Australia for children under five years but is not formally part of the national incentivised childhood vaccination schedule [15].