Parent Perspectives on Childhood Vaccination: How to Deal with Vaccine Hesitancy and Refusal?

Until legislation around childhood immunisation requirements for school admission was passed on July 31 2017 (Law no. 119), routine childhood vaccination was declining in Italy. Vaccine hesitancy (VH) refers to delay in acceptance or refusal of vaccines despite availability of vaccination services. The aims of the study were to evaluate attitudes about childhood vaccines and vaccine refusal or delay among parents and to assess the role played by the variables mapped as potential determinants to suggest strategies that could improve childhood vaccination rates.

Conducted from April to June 2017, this cross-sectional survey was intended for parents having at least 1 child aged 1-5 years attending kindergarten in the geographic area of Catanzaro and Cosenza, in the South of Italy. Parental attitudes were measured using the Parent Attitudes about Childhood Vaccines (PACV) survey, to screen for VH. Briefly, the PACV contains 15 items under 3 domains (behaviour, safety and efficacy, and general attitudes). In addition, selected factors were grouped in 3 categories (contextual, individual, and group and vaccine/vaccination-specific influences) and explored as potential determinant of VH and vaccination refusal or delay. The dichotomous outcome variables for the analysis were VH measured as PACV score (0 = score < 50; 1 = score <50) and parental refusal/delay (0 = non refusal, 1 = refusal).

Among the 575 parents who completed the survey, 7.7% were defined as VH parents (VHPs) through PACV score, while 24.6% reported having refused or delayed at least 1 dose of vaccine for their child. PACV is a measure of the attitudes towards vaccines, and discrepancies between attitudes and actual behaviour have been of concern to investigators. The researchers suggest that the inconsistency between PACV score and vaccines refusal/delay could be explained by the fact that VH is considered a complex and context-specific issue, and its determinants could vary among different countries. Hence, there may be additional cultural nuances in attitudes and beliefs among parents that the standard PACV did not capture in this particular setting, such as anti-vaccinationist influences and trust in the National Health System (NHS) - see below.

Potential VH determinants:

• Contextual influences: Only 37.1% of the parents reported seeking information about vaccination from a paediatrician, and 12% of them reported that the decision to vaccinate their child was based on information received from the mass media. In general, 34.2% of them thought that the NHS workers were not well informed on vaccination, and 20.2% did not agree with the decision of the Ministry of Health to make some vaccinations mandatory. Of note, 34.8% of the respondents thought that infant vaccinations represent an economic business for pharmaceutical companies, while 22.6% were uncertain.
• Individual and group influences: Adverse reactions after a dose of vaccine were reported to have occurred in 33.9% of children; in 11% of them, this event had influenced the decision to submit the child to other vaccinations. Fifteen percent of parents expressed a medium-low level of agreement with the usefulness of vaccination for the prevention of infectious diseases. Almost 20% of parents stated that the paediatrician did not provide enough information on childhood vaccinations, and 19% reported no trust in the information received. 16.9% thought that mass vaccination did not protect those who cannot be vaccinated, and almost 20% were insecure or disagreed with the obligation that children be vaccinated in order to be admitted to school.
• Vaccination-specific issues: 28% of parents believed or were unsure that vaccines are well tolerated by children, and more than half of them (51.2%) thought they needed more information about child vaccination. 51.1% of the parents believed that it is safer to administer fewer than 3 vaccines at one time. In 11.8% of cases, parents reported to have been discouraged by the paediatrician to have their child vaccinated.

VH was more common in those parents who: decided not to vaccinate their child after having received information from mass media; did not agree with mandatory vaccinations; agreed with political leaders who oppose vaccination; agreed that infant vaccinations are primarily an economic business of pharmaceutical companies; and disagreed that access to the kindergarten should only be allowed for children who had been vaccinated.

In conclusion, the findings of this study highlight potential determinants of VH, such as communication and the media environment. The researchers point to the fact that mass media are widely used for information seeking in the general population, particularly the internet, where misinformation and inaccurate data are widespread. In that context, healthcare providers (HCPs) could act as key actors to improve public trust in scientific and epidemiological evidence. However, "great effort needs to be made in the way health institutions deal with communication to the general population about vaccines, and it must be able to reach families." Open dialogue is recommended to build trust and to guide parents to choose wisely about childhood vaccination. Finally, longitudinal research is needed to better characterise the trends in the incidence of VH and vaccination refusal or delay.