ReviewFactors underlying parental decisions about combination childhood vaccinations including MMR: A systematic review
Introduction
Parental choice to decline childhood vaccinations is recognised as an important factor in suboptimal uptake [1], [2], [3], [4]. In recent large UK studies where unimmunised cases made up on average 5% of all children studied, three quarters of parents whose children were unimmunised with the measles, mumps and rubella (MMR) vaccine [1] and almost half of parents whose children were unimmunised with the primary schedule of vaccines (at that time diphtheria, tetanus, pertussis and Hib combined, oral polio and meningitis C) [4] said they had made a conscious decision to reject the vaccine. Such decisions are rooted in complex belief structures, and by understanding and modifying these beliefs it may be possible to influence decisions, thereby improving uptake. To this end, many studies have examined parental beliefs about childhood vaccinations [3], [5], [6], [7]. Studies have been conducted in numerous countries, with various vaccines, and differing vaccination policies and vaccine-preventable disease prevalence. Further, these studies span several decades, taking in multiple vaccine scares and disease outbreaks.
To impact significantly on the conduct of policymakers, parents, practitioners and researchers, this existing large body of evidence must be rendered accessible using objective methods. There are no up-to-date, systematic reviews of parental beliefs about and attitudes toward childhood vaccination suitable to inform local or national interventions to improve vaccine uptake. Narrative reviews identify a number of factors which may influence vaccine uptake, including practical barriers to and facilitators of uptake, media and lay representations of disease and vaccination, and trust in healthcare providers [3], [5], [8], [9]. Three systematic reviews identify commonalities in the evidence base which generally support the conclusions of narrative syntheses, however their methodologies and scopes limit their suitability to inform current policy and practice [6], [10], [11]. The most recent of these [6] reports research on parental beliefs only as a small component, and comprises both empirical and anecdotal evidence about the views of parents and health professionals. A slightly older review [10] considers only qualitative studies reporting barriers to uptake of the entire vaccine schedule. These studies may not be generalisable to a specific vaccine, because evidence suggests that uptake varies by vaccine [12], therefore that parents may not make decisions about the entire vaccine schedule, but rather about individual vaccines. The oldest review [11] used Bayesian meta-analysis to calculate the influence of various factors on vaccine uptake, but incorporated only studies published to July 1999 – predating the MMR controversy which took hold in the UK around the turn of the century [13].
This review aims to identify and synthesise evidence on which factors underpin decisions about combination vaccines (which protect against more than one disease in a single shot). Combination vaccines have been selected because it is “inevitable” [14] that more vaccines will be offered in combination rather than separately in the future [15], [16], and because combination-specific concerns may play a key role in parents’ decisions and behaviour (as indicated by some parents’ willingness to pay for separate measles, mumps and rubella vaccines) but the extent to which these concerns are addressed in the literature is unclear.
Section snippets
Search strategy and selection criteria
MedLine (including in-process & other non-indexed citations), PsycINFO, EMBASE, Maternity and Infant Care and International Bibliography of the Social Sciences were searched through Ovid. Reference lists of seminal articles and contents lists of appropriate journals were scrutinised, and unpublished literature and non-journal publications from relevant agencies were sought.
Keywords and MeSH terms were generated around four facets dictated by the review question: parent, decision, child and
Characteristics of studies
Two-thirds of included studies (including all the qualitative studies) were conducted in the UK and Eire. A higher proportion of UK/Eire studies than studies from elsewhere reported on healthcare system/Government factors, non-official sources of information, decision-making and individual differences. There is little evidence of any systematic differences in findings between UK/Eire studies and studies from elsewhere, except on some demographic factors – parental education, income, family size
Discussion
This review identifies and synthesises quantitative and qualitative evidence on the factors underlying parental decisions about combination childhood vaccines. Quantitative data demonstrate that generally parents making vaccination decisions act in accordance with their attitudes and beliefs about vaccine-related factors (Fig. 1). However, on some factors vaccine-acceptors and decliners did not differ. Accordingly, the qualitative data reveal that, whilst vaccine-acceptors generally hold
Acknowledgements
This review was funded by a Health Protection Agency Ph.D. studentship in Behavioural Science. The funder had no role in the conduct of the review or the decision to submit the paper for publication. The Clinical Safety Research Unit is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust which is funded by the National Institute of Health Research.
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