What Is 'Confidence' and What Could Affect It?: A Qualitative Study of Mothers Who Are Hesitant about Vaccines

Vaccine confidence is a relatively new concept in understanding vaccine acceptance or its relationship to vaccine hesitancy. Published studies to date have primarily used surveys to ask parents and others to indicate a level of confidence in the safety, effectiveness, or value of recommended childhood vaccinations. However, they have not provided insights into how parents may define confidence or what factors may reduce or increase vaccine-related confidence. Thus, the objectives of this study were to: (i) learn how mothers who are hesitant about vaccines characterise confidence when it comes to health-related products for their young children, including recommended childhood vaccines; (ii) gain insights into the factors that influence vaccine confidence beliefs; and (iii) assess whether short, education materials affect parental confidence in childhood vaccinations.

The qualitative study used eight 2-hour, moderator-led focus groups (6-9 participants per group) with 61 mothers of children 5 years old or younger who are hesitant about childhood vaccination. The focus groups took place in 2 metropolitan areas in the United States (US) in April and May 2016. In that country, the percentage of paediatricians encountering parents seeking to refuse a recommended childhood vaccination increased from 75% in 2006 to 87% in 2013, while 13% of parents in a 2010 national survey reported following an alternative schedule. Other studies cited in the paper suggest that 5.5-27% of US parents have delayed recommended vaccinations, and 3.6%-15% have declined recommended vaccinations.

The focus group moderator's guide had 4 major discussion sections: (i) health issues and concerns pertaining to children 5 years old and younger, including questions related to parents' definitions and perceptions of confidence in health products and vaccines; (ii) confidence considerations, including questions around factors that fostered or inhibited parent confidence, how one’s vaccine confidence related to vaccination behaviours, and what could build or instill confidence; (iii) vaccination-related confidence, including a series of questions related to childhood vaccine safety and efficacy; and (iv) exposure to 3 paired sets of education materials, with each set consisting of a 2- to 3-minute-long video and an infographic poster. Materials used positively framed messages (e.g., vaccines keep you healthy vs. vaccine-preventable diseases (VPDs) kill you). The videos were selected from YouTube (see below for one example of a video shown), while the infographics came from sources that provided vaccine-related education and information materials. After exposure to a set of materials, participants were taken through a series of closed and open-ended questions to gauge their understanding of the main messages and whether the materials affected their confidence in childhood vaccines.

The study found that:

• "Confidence” was associated with trust, having control, high familiarity, satisfaction with one's knowledge, and positive beliefs regarding effectiveness, safety, and the likely outcome.
• Low confidence was associated with distrust, safety concerns, and uncertainty, particularly regarding how a product worked, the resulting outcome, or the perceived need for the product.
• For medical products, mothers consistently indicated that trust, particularly trust in their child's physician, was necessary for them to be confident in a recommendation.

Reasons vaccine-hesitant mothers cited for being confident in recommended vaccinations included: familiarity or personal experience with the vaccine; satisfaction with one's research regarding the vaccine; perceived severity of the VPD, and high trust in their child's health care provider. However, they cited many reasons for having little to no confidence, for reasons including: not having enough time to learn about a vaccination or to make a vaccination decision; uncertainty about how vaccines interacted with a child immune's system (particularly when the child was very young); belief that the vaccine could cause illness; lack of information about issues they were concerned about (e.g., vaccine ingredients or the basis for the recommended immunisation schedule); and safety concerns (e.g., wanting to avoid any type of vaccine reactions and/or concern about long-term harm).

None of the videos or infographic posters used in the study clearly positively affected parents' confidence levels; nor were there any materials that resonated the same across groups. Most, however, had elements or components that appeared to have the potential to positively affect confidence levels. Table 4 in the document summarises the key findings for the 3 sets of educational materials. In general, the short videos were received more favourably than the infographics, with most participants stating the videos did a better job of showing the concepts because of the use of animation, colours, sounds, and familiar analogies. Some noted that the infographics were boring and failed to hold their attention.

Participants suggested that educational efforts to increase parents' confidence need to be aligned with the interests, concerns, and assumptions of parents who are hesitant and that: (i) animation can be perceived as "childish" if the approach is overly simplistic; (ii) use of everyday objects (e.g., candy) to explain a scientific concept may appeal to some but seem condescending to others; (iii) parents generally responded favourably to the creativity used in the videos to explain concepts like how vaccines work or herd immunity; and (iv) video explanations can cause some confusion or introduce new questions. For example, the video on how vaccines work prompted additional questions about how the immune system works and the necessity of vaccines.

The themes surfaced here indicate that while trust is a major component of confidence, parents' vaccine confidence also encompasses having a sense of control, familiarity and experience, satisfaction with one's knowledge, and a high degree of certainty regarding the outcome. This suggests that instilling or strengthening parents' confidence in vaccines, whether during a physician conversation or through education materials, might benefit from recognising or addressing these factors, particularly if the vaccine or recommendation is relatively new. Similarly, the validity of efforts to measure parent vaccine confidence may increase if they include items that assess these dimensions.

Among mothers' suggestions for improving their confidence were:

• More and/or better information, including on: why recommended vaccines are needed, vaccine ingredients (why are they there, how do you know they are safe), and short- and potential longer-term side effects.
• Enhanced empathy and understanding: doctors and healthcare providers being empathetic to, and understanding of, their vaccine questions, concerns, fears, and hesitancy; and doctors and healthcare providers seeing "my child" as unique.
• Increased parental control and involvement over timing and scheduling of recommended vaccinations.

In conclusion: "The findings suggest that vaccine-related information does and can play a significant role on parents' confidence, but leveraging information to increase confidence, particularly among parents who are hesitant, requires more work than many likely imagine."