A Systematic Review of Methods to Improve Attitudes Towards Childhood Vaccinations

A wide variation in vaccination rates exists between states and local communities in the United States (US). In this country, there has been approximately a 70% increase in vaccination refusal for children born in 2013 as compared to children born in 2010. In this context, the objective of this study was to identify effective techniques to decrease vaccine refusal and increase the childhood vaccination rate.

Before detailing the review's methodology, the researcher, Rawan Nour, examines the beliefs and claims of vaccine-hesitant parents and anti-vaccinationists, as well as their impacts on individuals' behaviours, arguing that understanding this background is fundamental for creating and compiling strategies to address anti-vaccine sentiment. Nour examines 3 psychosocial theories and models of behaviour - the health belief model (HBM), the theory of planned behaviour (TPB), and social cognitive theory (SCT) - as applied to vaccination uptake rates. She then explores 3 determinants of vaccine hesitancy among parents:

• Environmental: the patient-health professional relationship, social norms and collective values, school immunisation requirements, media and communication, and vaccine policies. For example, collaboration between health professionals and public health and educational institutions could instill social norms and collective values that encourage individuals to be compliant and get vaccinations, even if there is misinformation or sensationalised stories about vaccine injuries circulating in media and communication outlets.
• Vaccine-specific: vaccine efficacy and safety and disease susceptibility perception. The more that parents believe that vaccines are safe and effective and that they are susceptible to acquiring the disease, the more likely they'll accept vaccinations for themselves and their children.
• Parental-specific factors: demographics and the parent's decision, knowledge, and past experiences. For example, it has been found that parents with a lower educational level are more likely to be vaccine-hesitant. The information they are exposed to about vaccines and their effects could be limited, and they are less likely to seek out alternative sources.

The researcher undertook a systematic review of English peer-reviewed articles published in the years 2000 to 2019. A total of 9 journal articles were identified, including 5 systematic reviews, 1 case study, 1 randomised controlled trial (RCT), 1 literature review, and 1 quasi-experimental study.

There were 3 motifs present among the articles:

1. Technological: Four journal articles evaluated and recommended technological strategies, including 1 case study and 3 systematic reviews. All 4 articles identified the importance of understanding the climate of vaccination attitudes and the characteristics of the individuals that are vaccine-hesitant or are anti-vaccinationists. In addition, they all analysed social media platforms and websites as a modality to promote vaccination coverage. For example, articles by Finnegan et al. and Cornelia et al. determined that storytelling articles and answers to frequently asked questions on websites were found to be effective and were more attractive to those seeking vaccine information.
2. Mass marketing or campaigning: Three journal articles proposed and analysed mass marketing or campaigning strategies, including 1 RCT and 2 systematic reviews. All articles emphasiaed the importance of understanding the population before implementing marketing or campaigning strategies and identified social marketing as an effective tool for vaccine promotion. In addition, they all acknowledged that successful campaigns are tailored to different subgroups of the population at different times and continuously. For example, an RCT conducted by Pluviano et al. concluded that a tailored approach accounts for attitudes, social norms, standards, and structural barriers. Storytelling can be effective in conveying accurate and comprehensible vaccine information, which, in turn, can promote vaccine coverage.
3. Direct communication strategies: Two journal articles proposed and analysed direct communication strategies, including 1 quasi-experimental study and 1 literature review. Both articles highlighted the significant role that healthcare providers play in addressing vaccine hesitancy and anti-vaccine sentiment and the importance of fostering trust and a healthy relationship between the patient and clinician.

Based on this review, Nour suggests that a combination of technological, mass marketing or campaigning, and direct communication strategies is integral for identifying the root causes of anti-vaccine sentiment and vaccine hesitancy and for devising ways to modify beliefs and promote vaccination coverage. She points especially to the World Health Organization (WHO) resource Tailoring Immunization Programmes (TIP), suggesting that it could be used in conjunction with visually enhanced educational materials in the context of a positive, trusting, and nurturing patient-clinician relationship. By using motivational interviewing skills, the clinician can, among other things, identify any barriers that the patient has to vaccination, including financial and psycho-sociological barriers. Once the barriers are identified, the information could be collected to determine and compile the population's characteristics that face the same barriers and, in turn, create a tailored approach using TIP. Health information technology could help in this endeavour of collecting and analysing patient information as part of constructing TIP, though there are privacy concerns.