An integrative review on parents’ perceptions of their children’s vaccinations

Abstract

An integrative literature review was conducted for studies published between January 2005 and January 2016 to obtain evidence on parents’ experiences and perceptions of vaccinations. Considering the mandatory nature of vaccinations in many countries and the influences of parental experiences on the outcome of vaccinations, it is essential to understand the experiences and needs of parents regarding their children’s vaccinations. CINAHL, PsycINFO, PubMed, Scopus and ScienceDirect were searched for data. In this review, 20 studies (10 quantitative and 10 qualitative) that related to parental perceptions regarding their child’s vaccination were included. The parents had varied views on vaccination and they had many vaccination-related concerns and difficulties. Different factors influenced their vaccination decisions and they had varied support needs. This review found that exploring parental perceptions regarding their child’s vaccination in terms of the attitudes and experiences of parents, how these affect vaccination decisions as well as the needs of parents regarding their children’s vaccinations is important in multicultural societies.

Keywords

Children experiences integrative review parents vaccination

Introduction

Vaccinations play an important role in preventing diseases, thereby protecting the community from various infectious illnesses (Farren and McEwen, 2004). The World Health Organization (WHO) recognizes vaccinations a cost-effective health intervention, given its range of outreach and simple administration process (WHO, 2015). Maintaining high vaccination rates is important in reducing the incidence of vaccine-preventable diseases in both individuals and communities through herd immunity (Dubé et al., 2012). Childhood vaccination policies vary among countries. Some mandate a vaccination schedule and/or provide financial incentives to vaccinate, while others allow the decision to vaccinate to be left wholly to individual parents (Walkinshaw, 2011). Given the compulsory nature of vaccinations in some countries, vaccination can form a significant portion of child’s healthcare experiences.

Existing literature has revealed that parents viewed taking their child for vaccinations as a social responsibility (Tickner et al., 2010). However, it was common for parents to have low confidence in their vaccination decisions, even in communities with high vaccination rates (Allan and Harden, 2015; Austvoll-Dahlgren and Helseth, 2010). While adhering to recommended vaccination schedules, parents continued to have multiple questions, concerns or misperceptions regarding vaccinations (Benin et al., 2006; Kennedy et al., 2011b; Mills et al., 2005), causing them to experience anxiety before, during and after vaccination (Luthy et al., 2013; Yaqub et al., 2014). Parents’ experiences of their child’s vaccination may also affect their children’s experiences. For instance, high levels of parental anxiety may increase their children’s anxiety levels and consequentially the pain experienced by their children (Bearden et al., 2012). Previous research has shown that parents’ experiences have stronger influence on their decisions than scientific evidence (Brown et al., 2010; Jones et al., 2012). Parents’ experiences of their child’s vaccination therefore influence their vaccination decisions (Kempe et al., 2011). Vaccine hesitancy or refusal among parents of young children would affect acceptance and timely coverage of vaccination, thereby threatening the effectiveness of vaccination programmes (Barrows et al., 2015; Dubé et al., 2012).

Understanding the experiences and needs of parents regarding their children’s vaccinations would be useful in improving holistic vaccination experiences and maintaining high vaccination rates. Systematic reviews conducted previously (Allan and Harden 2015; Brown et al., 2010; Mills et al., 2005; Yaqub et al., 2014) tended to focus mainly on the particular type of vaccine such as measles, mumps and rubella, and only analysed research conducted in Western societies. Therefore, exploring previous literature on parents’ perceptions from varying societies regarding their children’s vaccinations in general will allow consolidation of the research in this lesser explored area.

Aim of this review

The aim of this literature review is to summarize the current body of evidence and provide a comprehensive overview of the perceptions of parents with children eligible for vaccinations, in order to identify any gaps in existing literature and practices. Ultimately, we aim to synthesize the evidence from research conducted across multicultural societies to improve healthcare practices.

Methods

Design and search strategy

An integrative literature review was conducted. Cochrane and Joanna Briggs Institute (JBI) databases were explored to identify any previous reviews available on the topic of interest. After which the following databases were searched to identify appropriate articles for this review: CINAHL, PsycINFO, PubMed, Scopus and ScienceDirect. The keywords used were ‘parent’, ‘mother’, ‘father’, ‘perception’, ‘view’, ‘experience’, ‘immunization’ and ‘vaccination’. Relevant articles were retrieved from database suggestions and also from the reference lists of chosen articles. Journal articles were included in this review if they (1) were available in English and published between 2005 and 2016; (2) were primary research studies that were either quantitative or qualitative; (3) involved mandatory and optional vaccines; (4) were limited to those involving children below six years of age, due to the unique nature of a parents’ role during preschool vaccination and (5) achieved at least 60% of the JBI criteria for methodological quality. Studies were excluded from this review if they (1) recruited parents of children with disabilities and/or (2) involved school-based vaccination. All research articles included in this review achieved at least 60% of the JBI criteria. Two authors appraised the quality of each paper independently, and any disagreements were resolved through a third author.

Data extraction and synthesis

A thematic synthesis framework was used to synthesis the findings (Ring et al., 2010). Based on this method, analytical themes were identified through descriptive synthesis in order to organize the findings relevant to the research aim. A table was created where researchers extracted information based on aims, methodology, sample and setting, data collection, data analysis, conclusions, strengths and limitations and future implications of included studies. For data synthesis, common themes were looked at by each researcher and weekly meetings were conducted between the first and the corresponding author to discuss themes. Differing findings were discussed until a mutual agreement was reached to preserve trustworthiness of the data synthesis (Polit and Beck, 2013).

Results

From the initial search yield of 1685 articles, 26 full-text articles were retrieved and assessed for eligibility. From the 26 studies, 6 were excluded due to having specific populations with extremely limited transferability and generalizability and/or due to insufficient information for critical appraisal. Twenty articles were subsequently included in the review, of which 10 were qualitative and 10 quantitative studies (Figure 1). Of the 20 studies, 15 were conducted in Western countries, 4 in Asia and 1 in the Middle East. A summary table of the reviewed articles can be found in the Online Supplementary. Due to the mixed nature of the studies, statistical pooling of the results was not possible. As such, the findings from the studies were presented as a narrative summary under four categories: parents’ views on vaccinations, vaccination-related concerns and difficulties, vaccination decisions and parents’ vaccination-related support needs.

Figure 1.

PRISMA flow diagram on the outcomes of search strategies.

Parents’ views on vaccinations

A variety of views influenced parents’ vaccination concerns and decisions. Parents often viewed vaccinations as a social responsibility, whereby everyone had a duty to ensure that their children were vaccinated (Tarrant and Thomson, 2008; Tickner et al., 2007, 2010). Others also saw vaccinations as a parental responsibility (Tarrant and Thomson, 2008; Tickner et al., 2010), a tradition (Pal et al., 2014) or an obligation constructed into daily life (Figueiredo et al., 2011).

Social influences may affect views and subsequent decisions regarding vaccinations. For instance, social views that influenza vaccination protects against flu, increased the vaccination rates post flu season (Daley et al., 2006, 2007). Alternatively, parents reported disapproval when friends did not adhere to the recommended vaccination schedules (Tickner et al., 2010), implying the possibility of social pressure. Parental views of vaccinations as a responsibility or social norm were subsequently associated with higher vaccination rates (Benin et al., 2006; Pal et al., 2014; Tarrant and Thomson, 2008; Tickner et al., 2010).

Experiences of the vaccination process may also influence parental views (Chen et al., 2011, 2015). Negative past experiences, like impatient staff and poor communication, may result in parents’ negative views regarding vaccinations (Delkhosh et al., 2014). Experiencing confusion with vaccination schedules and uncertainty about their rights and responsibilities in decision-making also created a negative perception of vaccinations (Austvoll-Dahlgren and Helseth, 2010; Gust et al., 2005b). Nonetheless, regardless of their apprehensions, multiple studies show that parents recognized the benefits of vaccinations. Protection against vaccine-preventable diseases (Chen et al., 2015; Tarrant and Thomson, 2008; Tickner et al., 2007) and benefits of herd immunity (Stefanoff et al., 2010) were the attributable benefits. Studies mainly included mothers as their sample.

Vaccination-related concerns and difficulties

Parents reported facing multiple difficulties and concerns related to their children’s vaccinations. These included side effects, vaccination safety, vaccination-related pain and inconveniences. Long-term adverse effects like autism or vaccination-induced chronic diseases have long been a concern of parents (Gust et al., 2008; Kennedy et al., 2011a). Immediate short-term side effects such as fever, pain and excessive crying were another cause for concern (Delkhosh et al., 2014; Figueiredo et al., 2011; Kennedy et al., 2011a). Some parents also had concerns about vaccination safety, especially for combination vaccines (Chen et al., 2011; Kennedy et al., 2011a; Pal et al., 2014). Parents worried whether their children’s immune systems were developed enough to handle vaccinations that were given in a short span of time in the recommended schedules (Gust et al., 2005a, 2008; Tickner et al., 2007, 2010; Kennedy et al., 2011a). Vaccination-related pain and side effects were also often reported as the most common concern of parents, for instance, when multiple shots were required (Delkhosh et al., 2014; Figueiredo et al., 2011; Gust et al., 2005a, b; Kennedy et al., 2011a).

Parents also report difficulties related to the inconvenience of adhering to the vaccination schedule. A Hong Kong study found that the most common barrier to vaccinations was the time it took to receive them in public clinics (Tarrant and Thomson, 2008). Similarly, a Taiwan study found that employed caregivers were less likely to take up optional influenza vaccinations (Chen et al., 2011), a decision likely attributed to inconvenience. Parents also reported preferring flexible appointment times (Tickner et al., 2007, 2010), possibly due to busy schedules. Studies conducted in Western societies rarely explored such concerns and difficulties with adhering to timely vaccination.

Vaccination decisions

Vaccination decisions largely comprise vaccination compliance, vaccine hesitancy, requesting changes in recommended vaccination scheduling and vaccination refusal (Benin et al., 2006; Gust et al., 2005a; Tickner et al., 2010). Vaccination decisions were influenced by factors that served to promote or deter vaccination uptake.

Physician recommendation was the most commonly cited factor in influencing parents’ vaccination decisions (Chen et al., 2011, 2015; Dubé et al., 2012; Lau et al., 2013; Nowalk et al., 2007; Tickner et al., 2007). Physicians and public health nurses were the most reliable and major influence for vaccination uptake (Benin et al., 2006; Chen et al., 2015; Pal et al., 2014; Tickner et al., 2007). This emphasizes the importance of trust between healthcare professionals and parents in providing advice regarding their children’s vaccinations (Benin et al., 2006; Pal et al., 2014; Tarrant and Thomson, 2008; Tickner et al., 2007).

The type of information that parents received about children’s vaccinations was also a major factor in influencing vaccination experiences and decisions. Information regarding vaccination (Tickner et al., 2010), vaccine-preventable diseases (Tarrant and Thomson, 2008), vaccine scheduling (Nowalk et al., 2007; Tickner et al., 2007) and coping techniques during vaccinations (Austvoll-Dahlgren and Helseth, 2010; Chen et al., 2015) were identified as relevant information contributing to parents’ vaccination decisions. While healthcare professionals remained the most trusted source, parents reported having other sources of information, such as the media, with the Internet appealing more to younger parents (Pal et al., 2014; Tickner et al., 2010). Media exposure on disease cases also increased their perceived severity and promoted vaccination uptake substantially (Benin et al., 2006; Daley et al., 2007; Nowalk et al., 2007).

Social and cultural influences especially differences between the countries of origin in the published studies also affected parental choices regarding their children’s vaccinations. Advice from peers, family members and friends was found to be a source of information and social influence in making vaccination decisions (Lau et al., 2013; Tarrant and Thomson, 2008; Tickner et al., 2007, 2010). Different populations also had differing influences; siblings and peers with children were found to be more influential than parents in giving vaccination advice in Hong Kong (Tarrant and Thomson, 2008), while maternal mothers were found to be most influential in England (Tickner et al., 2007). Additionally, cultural influences, such as religions dissuading vaccinations, were reported by populations in areas like Iran (Benin et al., 2006).

Accessibility and affordability of vaccination services also promoted vaccination uptake. Communities with high vaccination rates had easy access to vaccinations, or free or affordable vaccination services, such as in New Zealand (Pal et al., 2014), Taiwan (Chen et al., 2015) and Hong Kong (Tarrant and Thomson, 2008). This finding was supported by other studies, which reported fragmented care, cost and inconvenience as barriers to vaccination uptake. (Daley et al., 2006, 2007; Dubé et al., 2012), while other commitments, including work and other children, were reported to cause delayed vaccinations (Tickner et al., 2010).

As presented above, parents had a variety of concerns in relation to their children’s vaccinations and conducted their own weightage of the benefits and risks of vaccinating their children (Tarrant and Thomson, 2008). Self-efficacy or the parents’ perception of their own abilities to handle vaccination experiences also informed vaccination decisions (Austvoll-Dahlgren and Helseth, 2010; Chen et al., 2015), and these factors differed among parents.

Parents’ vaccination-related support needs

Healthcare personnel were most often reported as the main and most trusted source of vaccination information (Austvoll-Dahlgren and Helseth, 2010; Delkhosh et al., 2014; Gust et al., 2005a, 2008; Kennedy et al., 2011a; Stefanoff et al., 2010). This trust is associated with higher vaccination rates (Dubé et al., 2012). Studies highlighted the importance of establishing a trustworthy parent–healthcare worker relationship, including being patient and sustaining the relationship over time, and treating parents with a whole-person approach (Benin et al., 2006; Delkhosh et al., 2014).

The nature of the information provided was also important in influencing vaccination experiences and decisions. Parents reported being more receptive to information catered to their educational levels (Delkhosh et al., 2014) that were non-judgemental (Gust et al., 2008). Parents also preferred information that had scientific basis (Benin et al., 2006) and was supported by simple statistical evidence (Gust et al., 2008). In addition, parents wished to receive objective information rather than information facilitating vaccination uptakes, in order to make informed decisions confidently (Austvoll-Dahlgren and Helseth, 2010; Gust et al., 2008). Parents also had needs related to inconveniences and complexities of vaccination processes. Flexible appointment times and reminders facilitated timely adherence to vaccinations (Nowalk et al., 2007; Tickner et al., 2007).

Discussion

This review focused on the perceptions of parents regarding their children’s vaccinations, which were categorized into differing views, concerns, difficulties, subsequent decisions and their needs.

From this review, one can understand how and why the perceptions of parents may differ regarding vaccinations. The literature review identifies how benefits, risks and necessity are often weighed in making vaccination decisions, whereby the health belief model was most commonly implemented to understand vaccination beliefs and behaviours (Chen et al., 2011, 2015; Daley et al., 2006, 2007; Lau et al., 2013). It is important to recognize that parental views and subsequent decisions did not have straightforward relationships. For example, a study on the perceptions of parents in a highly immunized community of Hong Kong showed that supporters of vaccinations readily admitted knowledge deficits (Tarrant and Thomson, 2008), while a study in the United States found that vaccine acceptors had poorer knowledge regarding vaccinations than those who chose to delay their children’s vaccinations (Benin et al., 2006).

Parents also had a variety of needs that determined their perceptions of vaccinations. Even in communities with high vaccination compliance rates, parents had concerns and misperceptions regarding their children’s vaccinations (Austvoll-Dahlgren and Helseth, 2010; Benin et al., 2006; Daley et al., 2007; Tickner et al., 2010; Yaqub et al., 2014). It is therefore important to explore parental perceptions in different societies that have different factors of influence, which ultimately affect their vaccination decisions (Brown et al., 2010). Most of the studies in this review often involved only mothers’ perspectives, or otherwise did not differentiate the perceptions of fathers, leading to the possibility of fathers being under-represented. Demographic data were rarely linked to the findings on the views and decisions of parents regarding their child’s vaccination. The quantitative papers reviewed did not sufficiently explore the reasoning behind parental perceptions, while qualitative papers often stated limited generalizability due to small sample sizes.

In order to maintain the vaccination rates, it is necessary to recognize factors that promote vaccination uptake, such as cost considerations and accessibility (Pal et al., 2014). With the multitude of factors influencing vaccination decisions, it is also important that parents are confident in making informed decisions. The persistent misperceptions and knowledge deficits of parents (Benin et al., 2006; Daley et al., 2007; Tickner et al., 2010) thus warrant urgent attention.

Information tailored to parents’ needs and levels of understanding would promote positive attitudes towards vaccination (Allan and Harden, 2015; Figueiredo et al., 2011; Kennedy et al., 2011a). This suggests that healthcare providers have to be knowledgeable and utilize effective communication, providing specific and tailored responses (Figueiredo et al., 2011; Kennedy et al., 2011a; Yaqub et al., 2014). Effective education to promote vaccination needs to begin at pregnancy (Benin et al., 2006), when parents may be less tired and have more time to concentrate (Tickner et al., 2007). Healthcare professionals may also refer parents to trustworthy information supplements as an alternative (Austvoll-Dahlgren and Helseth, 2010).

Overall, healthcare workers and information provided to parents have great influence on their vaccination perceptions and decisions. Understanding vaccination processes and decisions and promoting convenience are also important in maintaining trust in healthcare and confidence in vaccination programs. This will sustain public health in the long run (Gust et al., 2005b, 2008; Tarrant and Thomson, 2008).

Limitations of the review

This review is limited in its generalizability as it focused on articles published in English in the databases stipulated. Information from non-English articles and articles published in grey literature may be omitted. Another limitation is the exclusion of systematic reviews, which may have offered more comprehensive findings on parental perceptions regarding their child’s vaccination.

Implications for nursing practise and future research

There are various gaps that need to be addressed in nursing practise and future research. Despite existing high vaccination compliance rates, healthcare professionals should be well-trained to assess informational and other support needs of both parents pertaining to vaccinations to provide necessary support and clear misperceptions. The focus should remain on providing individualized and standardized information, including common side effects and appropriate management. Timely education would combat busy schedules of parents and reduce parental anxiety due to uncertainties.

In this review, given that the quantitative studies used different instruments and measured different outcomes, statistical pooling of results was difficult. Furthermore, qualitative studies did not distinguish findings based on sociodemographic data. Ideally, future research should be mixed method using standardized tools to measure perceptions of parents on vaccination and triangulating the results with qualitative interviews from both fathers and mothers. Future research should also involve both parents by exploring their needs and evaluate educational programmes catered to individuals. Robust interventional studies should test various ways of satisfying the educational and related needs of both parents. Policymakers should invest in media coverage and public forums to create awareness and a support system for parents regarding their children’s vaccinations. Financial support for mandatory vaccines may serve as a motivator for some needy parents. A holistic approach needs to be taken to support parents whose children are undergoing vaccinations.

Conclusion

Exploring the attitudes and experiences of parents, how these affect vaccination decisions, as well as the needs of parents regarding their children’s vaccinations, allowed pertinent issues to be identified. The understanding that there are multiple factors affecting vaccination perceptions also shows that cultural and systemic factors may uniquely influence parental perceptions and experiences. Therefore, exploring parents’ experiences regarding their children’s vaccinations in different societies would offer insight on their concerns and needs in improving their vaccination experiences.

Footnotes

Acknowledgement

The authors would like to thank the National University Health System, Medical Publications Support Unit, for assistance in the language editing of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental material

Supplementary material for this article is available online.

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