A Deliberate Choice? Exploring Factors Related to Informed Decision-making about Childhood Vaccination among Acceptors, Refusers, and Partial Acceptors

"An open dialogue between parents and CVPs [child vaccine providers] may increase deliberation among parents, strengthen positive attitudes, prevent misperceptions, and resolve decisional conflict."

In recent years, vaccination coverage has declined in various countries, including the Netherlands. This qualitative study explores similarities and differences in factors related to decision-making about childhood vaccination among parents who accept (acceptors), refuse (refusers), or partially accept (partial acceptors) childhood vaccinations, examining whether these groups have similar knowledge and attitudes about childhood vaccinations and how they evaluated the pros and cons of accepting, refusing, and partially accepting childhood vaccinations.

Between February 13 2017 and March 2 2017, the researchers conducted 12 semi-structured focus group interviews in 3 large cities across the Netherlands: 3 with acceptors (n = 19), 3 with refusers (n = 12), and 6 with partial acceptors (n = 24) to ask about knowledge, attitudes, deliberation, and information needs. They then performed a thematic analysis of the transcripts.

Key results:

• Knowledge - While acceptors were able to report most evidence-based information about childhood vaccination during a mind mapping exercise, they expressed the most doubts about being well-informed. Refusers and partial acceptors reported different information based on studies and anecdotal evidence acquired on, for example, vaccine-critical websites and social media. They stated they felt very informed.
• Attitudes - The overall attitude of acceptors and partial acceptors was positive towards vaccinations. On the other hand, refusers discussed negative aspects about the Dutch National Immunization Program (NIP) and vaccines, such as the perceived early start of vaccinations, the lack of possibility to discuss alternatives and doubts with people in their social environment or with child vaccine providers (CVPs), the rigidity of a standardised schedule, the lack of transparency of the NIP, combination vaccines, and the perceived mandatory nature of the NIP.
• Deliberation - Acceptors viewed the decision to participate in the NIP as self-evident. In contrast, refusers and partial acceptors deliberated the pros and cons of the vaccine-preventable diseases (VPDs) versus side effects of vaccines. They also consciously deliberated the pros and cons of accepting or refusing each individual vaccination. They mentioned that this was an elaborate, time-consuming, and difficult process. They explained that it was difficult to find trustworthy information and that they did not feel supported in their decision-making.
• Information needs - Parents stated that several of their questions remained unanswered. They reported concerns about contradictory information being available, which they find difficult to navigate. Most parents mentioned that, when they asked their CVPs about the contradicting information, they received no or unsatisfactory answers - e.g., rather than just hearing that childhood vaccinations are safe, they wanted to know why vaccinations were safe or why vaccinations worked. Most parents agreed that the information provision about the NIP was currently inadequate (brochures and CVPs). They mentioned that the tone of voice of information about the NIP by CVPs is "patronizing, which made parents feel that they were perceived as stupid and bad parents". Lack of trust was related to one-sided information provided, and parents concluded that trustworthy information would discuss both pros and cons of childhood vaccination and would appeal to a variety of parents.
• Additional factors - For example, compared to acceptors, refusers and partial acceptors perceived fewer risks of VPDs, more risks of side effects of vaccines, less social support from their environment, and less trust in child welfare centres (CWCs) and in information provided. Acceptors strongly believed that childhood vaccination is an action that benefits not only their child (individual benefit), but also herd immunity (societal benefit), stating that their decision was confirmed by a strong social norm expressed by friends, parents, and the CWC, which reinforced their decision to accept vaccinations. Refusers and partial acceptors felt criticised by the same social norm in society - e.g., that refusal is "selfish".

Based on these findings, the researchers suggest that stimulating an open dialogue between parents and CVPs may increase parents' feeling of being informed. "The lack of discussion with CVPs, the perception that childhood vaccination is self-evident, and the patronizing tone of voice of CVPs may leave parents vulnerable for anti-vaccination messages about alleged risks and side-effects of childhood vaccination..." More elaborate dialogues between CVPs and parents could build trust between parents and CVPs, could be used to discuss the evidence-based advantages of childhood vaccinations, and could decrease parents' susceptibility to anecdotal information and misperceptions about childhood vaccinations shared by other parents.

To increase factual knowledge about childhood vaccination and facilitate discussion skills among CVPs to build trusting relationships with parents, the Dutch National Institute for Public Health and the Environment (RIVM) developed an e-learning tool. "While further research and monitoring is needed to evaluate the implementation, adoption, and effectiveness of this tool, these changes and measures may stimulate an open dialogue, increase informed decision-making, reduce decisional conflict, and increase trust between parents and CVP professionals..." In addition, funds were made available by the government to reduce time constraints to discuss childhood vaccination with parents in 2017-2018.

In addition to population serveys to gain more insight into which factors played a role in informed decision-making about childhood vaccination, the researchers suggest further research to test how a combination of numeric risk communication and narratives can inform parents. Also, refusers appeared to be interested in hearing more about partially accepting childhood vaccination instead of refusing the NIP. Although not ideal, compared to refusing childhood vaccinations, there are more health benefits associated with partially accepting the NIP. Further research could investigate the individual and public health effect of informing parents about these options of childhood vaccinations.