Parents' and Informal Caregivers' Views and Experiences of Communication about Routine Childhood Vaccination: A Synthesis of Qualitative Evidence

"People involved in vaccine programmes need to understand how parents experience different types of communication about vaccination and how this influences their decision to vaccinate their child."

The aim of this Cochrane review was to explore how parents experience communication about vaccination for children under 6 years of age. Specific objectives were to identify, appraise, and synthesise qualitative studies exploring: parents' and informal caregivers' views and experiences regarding communication about childhood vaccinations and the influence that vaccination communication has on parents' and informal caregivers' decisions regarding childhood vaccination. This review is part of a larger project entitled Communicate to Vaccinate (COMMVAC), exploring communication regarding childhood vaccination through Cochrane reviews and other approaches; see Related Summaries, below.

The context of the review is that, although childhood vaccination is an effective way of preventing serious childhood illnesses, many children do not receive all of the recommended immunisations. Some parents do not have access to the vaccine; others do not trust the vaccine itself or the healthcare worker who provides it, or they do not see the need to vaccinate their children at all. To address issues, governments and health agencies often try to communicate with parents about childhood vaccinations. This communication can take place at healthcare facilities, at home, or in the community. Communication can be two-way, for instance face-to-face discussions between parents and healthcare providers. It can also involve one-way communication - for instance, information provided through text messaging, posters, leaflets, or radio or television programmes. Some types of communication allow parents to actively discuss the vaccine, its benefits and harms, and the disease it aims to prevent. Other types of communication simply give information about these issues or about when and where vaccines are available.

As part of the review, the researchers selected 38 titles and abstracts published between 1998 and August 30 2016 for inclusion in the synthesis. Most of the studies were from high-income countries and explored mothers' perceptions of vaccine communication. Some of the studies also included the views of fathers, grandmothers, and other caregivers. Only one study exclusively focused on a vaccination campaign (specifically, a polio campaign in India). The researchers assessed their confidence in the findings using the GRADE-CERQual approach. High confidence suggests that it is highly likely that the review finding is a reasonable representation of the phenomenon of interest, while very low confidence indicates that it is not clear whether the review finding is a reasonable representation of it. Using a matrix model, they then integrated their findings with those from other Cochrane reviews that assessed the effects of different communication strategies on parents' knowledge, attitudes, and behaviour about childhood vaccination.

Forty-three findings are outlined in the document. To cite some of the major ones, in general, parents wanted more information than they were getting (high confidence). For some parents, a lack of information led to worry and regret about their vaccination decision (moderate confidence). Parents wanted balanced information about both the benefits and risks of vaccination (high confidence), presented in a clear and simple manner (moderate confidence) and tailored to their situation (low confidence). Parents wanted vaccination information to be available outside of the health services (low confidence). They wanted this information in good time before each vaccination appointment and not while their child was being vaccinated (moderate confidence).

"Parents wanted to receive specific, balanced information, communicated in a clear and simple manner, and in a language they understood about both the benefits and harms of vaccination. Parents wanted information that was relatable and tailored to their situation, including their attitudes towards vaccination. They wanted information to be presented in a variety of ways including through mHealth interventions such as text messaging. Many parents, regardless of their attitudes towards vaccination, believed that their decision to vaccinate had been inadequately informed. This could cause worry and regret about their vaccination decision."

Parents viewed health workers as an important source of information and had specific expectations of their interactions with them (high confidence). Poor communication and negative relationships with health workers sometimes impacted on vaccination decisions (moderate confidence). Parents generally found it difficult to know which vaccination information source to trust and found it difficult to find information that they felt was unbiased and balanced (high confidence). The amount of information parents wanted and the sources they felt they could trust seem to be linked to their acceptance of vaccination, with parents who were more hesitant wanting more information (low to moderate confidence).

The synthesis and comparison of the qualitative evidence shows that most of the trial interventions addressed at least one or two key aspects of communication, including the provision of information prior to the vaccination appointment and tailoring information to parents' needs. None of the interventions appeared to respond to negative media stories or address parental perceptions of health worker motives.

As outlined in the report, the following questions, derived from the findings, may help programme managers and other stakeholders to assess whether the vaccination communication interventions they are planning adequately address the issues that are important to parents and informal caregivers:

1. Is vaccination information communicated to parents in good time before vaccine delivery and decision-making about vaccination, in a context where parents have time to consider the information and come to a decision?
2. Is information about vaccination available at a wide range of health service and community settings? Is it possible for parents to have discussions in these settings about vaccination?
3. Is information about vaccination adapted to the needs of each family? For instance, vaccine-hesitant parents may need different types and amounts of information than vaccine acceptors.
4. Do health workers provide parents with and help them find neutral vaccination information tailored to their needs? Do they have open, respectful discussions with parents in a caring, sensitive, and non-judgemental way? Do they give clear answers to parents' questions? Do they provide a supportive environment for decision-making?
5. Are health workers perceived as being driven by financial gain rather than the best interest of the child?
6. Do parents perceive the vaccination information they receive as impartial, balanced, independent, and transparent?
7. Is vaccination information communicated to parents in a clear and simple manner and in a variety of formats?
8. Are vaccination communication strategies adjusted to respond to media stories, rumours, and negative publicity about vaccination in order to respond to parental questions and concerns these stories may have raised?

The authors offer implications for research as well. For example: "Further research, especially in rural and low- to middle-income country settings, could strengthen evidence for the findings where we had low or very low confidence." They note that there is a need for better reporting of context, sampling, methods, and researcher reflexivity in qualitative studies. For instance, more detail concerning setting and participants is needed to identify underlying cultural or social phenomena (shared values or beliefs) that mediate the influence of communications and should therefore be addressed when designing vaccination communication interventions. They argue that research about parental perceptions of vaccination information needs to include a broader spectrum of contexts. In particular, more studies are needed in low- and middle-income country (LMIC) settings and in rural settings in high-income countries (HICs). One of their other suggestions is that future qualitative studies on vaccination information consider the perceptions of informal caregivers and fathers and explore why some communication strategies do or do not influence parents' and informal caregivers' decisions about routine childhood vaccination. Furthermore, "[f]uture trials of vaccination communication should offer better descriptions of the communication interventions used in the study, including the training received by those delivering the vaccination information and how the information was developed and pre-tested. More detailed descriptions of home visits and discussions between health workers and parents/informal caregivers are also needed."