Abstract
Vaccinations are considered one of public health’s greatest accomplishments. Despite evidence for vaccine effectiveness, uptake levels are still well below the Centers for Disease Control and Prevention’s guidelines. The immunization decision-making process for parents is complex and depends on factors associated with knowledge and experiences. This qualitative study sought to expand on a previous decision-making model for immunizations by examining how individuals receive vaccination information, determining the role of experience in influencing decisions, and understanding how young adults might locate vaccination information in the future. Three focus groups were conducted with 29 undergraduate students without children. Results suggest that young adults exhibit an awareness of information regarding vaccine use and effectiveness, value doctor opinions and recommendations, and desire more robust research on vaccinations. Implications of these results include the importance of (1) disseminating vaccination education to young adults, (2) enhancing consistency/trust between medical professionals and youth, and (3) expanding public policy to increase vaccine uptake.
Introduction
Vaccinations have been essential in the reduction of disease-related mortality and are considered one of public health’s greatest accomplishments. 1 The World Health Organization estimates that vaccinations save between 2 and 3 million lives per year by protecting against serious illnesses such as measles, diphtheria, and pertussis. 2 In addition, vaccines have been the main contributors to the deterioration of numerous diseases including smallpox, measles, polio, rubella, and chickenpox. 3 While immunizations protect individuals against a variety of diseases, their effectiveness relies significantly on citizen utilization, referred to as vaccine uptake. 4 Vaccine uptake not only provides disease protection at the individual level but also decreases the macro-level risk of infection in the community. This indirect effect, known as herd immunity, suggests that a population’s immunized majority will protect those who are unvaccinated (eg, newborns, immunocompromised, etc).5,6 Health care professionals suggest that 95% of individuals need to be immunized in order to achieve effective herd immunity. 7
Despite the substantial evidence for vaccine effectiveness,1,8,9 uptake levels are still below the Centers for Disease Control and Prevention’s recommended vaccination guidelines. 7 Some have suggested that low vaccine uptake could be linked to barriers in vaccine access and services (eg, cost, transportation, insurance coverage, and appointments/scheduling), which could explain the lower immunization rates of high-risk communities.10-14 Although service barriers are important to consider when examining low vaccine uptake percentages, there are also an increasing number of parents voluntarily choosing not to vaccinate their children. Sturm et al 15 developed a model to identify factors impacting parental decision making within a vaccination context. This model posits that there are several factors influencing parental willingness to immunize, including social-environmental factors (ie, cultural attitudes, social group norms, and media coverage), parent-specific or personal factors (ie, parental beliefs about the perceived benefits and efficacy of vaccines and cognitive heuristics in decision making), the family’s interactions with the health care system (ie, health provider recommendation, communication, and vaccine cost and availability), institutional policies and interventions (ie, international initiatives about vaccines, federal and state mandates, and professional group recommendations), and the physical environment of health (ie, disease prevalence, new strains of bacteria and viruses, and available treatments). Of these factors, parental attitudes on childhood vaccinations have been identified as particularly important, with findings suggesting that roughly 5% to 10% of individuals endorse strong antivaccination beliefs, and 20% to 35% are “vaccine hesitant,” a term describing apprehension regarding vaccine utilization.16,17 “Vaccine hesitant” parents cite a variety of reasons for their resistance to vaccinating their children (eg, religious, political, emotional, or scientific). This increased skepticism has resulted in delayed vaccination schedules, undervaccinated children, and nonvaccinated children. 14
Parental immunization concerns include fear of potential side effects, vaccination ineffectiveness, fears of overloading a child’s immune system, and parents’ own personal experiences of adverse events following immunization.18-20 Additionally, the most frequently discussed reason for not vaccinating children is a lack of knowledge about vaccines.4,20,21 The link between limited access to vaccine information and lower vaccine uptake rates has been demonstrated across a variety of populations, including parents, health care providers, and high school students.13,22-24 Clearly, the parent decision-making processes surrounding immunizations is complex and depends on many factors within the individual’s knowledge and experiences. The heightened number of vaccination concerns and limited available information suggests that these concerns need to be better understood among young adults making immunization decisions in the coming years.
This study aimed to better understand the decision-making model of Sturm et al 15 for the upcoming generation by examining prospective parental beliefs and attitudes on immunizations via focus group interviews. More specifically, the study sought to examine how individuals receive information regarding vaccinations and determine the role of personal experience (with parents, doctors, friends, etc) in influencing vaccination decisions.
Methods
Participants
Participants consisted of 29 undergraduate students at a large Midwestern University that participated in semistructured focus groups. Approval from the appropriate Human Subjects Research Institutional Review Board was obtained prior to administration of the study. Participants were predominantly female (75.9%) with an average age of 19.41 years. Participants self-identified as predominantly Caucasian (82.8%) or Hispanic/Latino (6.9%).
Focus Group Guide
An interview guide for participants was developed by the lead qualitative researcher and reviewed by the qualitative research team. The purpose of the semistructured guide was to assess opinions on immunizations and how participants would hypothetically immunize their child(ren) in the future. The interview guide used a semistructured approach in which the interviewer asked a number of questions on the topics of interest and utilized probing questions to gain additional insight on the beliefs of prospective parents. The guide began by asking participants about the importance of health care and immunizations for children in general. The guide then asked participants to reflect on their own personal opinions about immunizations, their plans for immunizing children in the future, and the accessibility of reliable immunization information.
Procedures
Participants selected for focus groups were identified using a screener questionnaire through the university’s research study recruitment platform. The screener evaluated current guardianship of a child and previous immunization decisions on the behalf of a child. Students who denied guardianship of any children were contacted via email by the research team about the opportunity to participate in a focus group. Focus groups were conducted solely with individuals without children to determine opinions and beliefs about vaccinations prior to making immunization decisions. Participants were all provided written consent forms for the research study. Each focus group included approximately 10 participants and lasted between 45 minutes and 1 hour. After the conclusion of the focus group, participants completed an online questionnaire that further assessed attitudes and knowledge related to immunizations.
All focus groups were audio recorded to guarantee the collection of all comments. After completion of the focus groups, a separate team of researchers transcribed the recordings. All recordings were transcribed by 2 separate research assistants and crosschecked by a third research assistant to ensure accuracy. During transcription, all identifying information of participants were removed.
Analysis of Qualitative Data
Analysis of focus group data was conducted using NVivo 10 qualitative analysis software. Themes were identified utilizing a structured, template approach. 25 Two members of the qualitative research team selected a sample of the focus group transcriptions and collaboratively created a codebook outlining both broad and specific themes.
Once the codebook was completed, 2 members of the research team independently coded each individual transcription. These codes were then compared across the 2 members using simple agreement to assess interrater reliability. Simple agreement is a commonly used method for assessing reliability in qualitative studies.26,27 While simple agreement does not account for coding agreement that may occur by chance, 26 answers given in this study were plentiful, varied, and not always mutually exclusive to 1 code; making the probability of coding by chance far less likely. 28 Average intercoder reliability was more than 80%.
From the coded themes, 2 sets of percentages were then calculated. First, the number of participants that commented at least once on each particular theme was summed and divided by the total number of participants who completed the qualitative portion of the study. This percentage assessed what proportion of participants spoke about a particular theme. Second, the percentage of total comments for each theme was calculated. This gave an indication of the emphasis and frequency that each theme received during the interviews.
Results
Knowledge of Common Illness or Disease
First, participants were asked to identify which diseases or illnesses could be prevented through immunization. Overall, focus group participants were aware of a variety of illnesses with the most frequently named diseases or illnesses being animal flus, polio, chicken pox, malaria, measles, mumps, smallpox, tetanus, and tuberculosis (Table 1).
“Common” Illnesses or Diseases as Defined by Focus Group Participants (N = 29).
Concern for Common Illness and Disease
Following identification of common illnesses and diseases, participants were asked if they had any concerns regarding contraction of the illnesses discussed. Figure 1 provides an illustration of the level of concern endorsed by participants. The majority of participants indicated no concern (48%), with additional participants indicating slight concern (44%) or no concern (3%). Furthermore, a small percentage of participants chose not share their opinion on their concern for common illness and disease.
Percentage of focus group participants indicating concern for common illness and disease.
Ideas on Immunization
Participants were also asked to discuss their general thoughts related to immunizations. Most frequently, participants indicted feeling positively, with participants stating that immunizations are beneficial overall and should be given to children. For example, one participant stated,
I think overall they’re a good thing . . . just preventing what you can prevent is beneficial for their health.
This was followed with a discussion that the decision to immunize should be done on a case-by-case basis with participants opting to take a more “natural” approach. Participants noted that they would allow their children to get some immunizations and decline others. For example, 2 participants stated,
I just am a full believer in building up the immune system and being more natural about my child with medicine and stuff. . . . so this one incident happened (illness of child) and so now they’ve made a vaccine for it or some medication to prevent that from happening (obscure vaccinations are not needed).
Other themes that emerged included an overall lack of knowledge regarding immunizations and lack of exposure to information, as well as the need for doctors to provide more information. Participants highlighted the need for further research on immunizations and emphasized that immunizations should be provided in a way that is convenient and free of charge. Inter-estingly, participants questioned the need for immunization in today’s society, as several stated that diseases have been eradicated.
Immunization Concerns
Focus group participants discussed concerns regarding negative health side effects of immunizations, with several themes emerging in this area. The most common theme was general medical side effects that might affect health after administration of immunizations. While a number of participants discussed their own personal experiences with having medical side effects from immunizations, many discussed information they had heard secondhand (not from medical professionals) of possible side effects. Additionally, participants indicated that they were unaware of long-term medical side effects from immunizations, for example, one participant noted,
The unknown. What could happen if they haven’t done any research on it yet or thinking about how the vaccine, or what the vaccine is treating could change over time. So the actual thing that it’s preventing, so it could just develop into something else over time into a different disease or something.
Another potential concern involved the possibility of allergic reactions to immunizations with some participants sharing personal or family experiences as well as stories they had heard secondhand. For example,
One of my sisters had an allergic reaction to Gardasil . . . none of the rest of us got it because hers was so bad.
An additional theme that emerged was that immunizations could cause disease. Some of the fear was surrounding immunizations not working and causing general disease in the child, with additional comments about personal experiences of getting a flu shot and feeling as though it was the cause of subsequent flu-like symptoms. An example quote is,
. . . like a weak baby . . . where that can be more damaging . . . obviously immunization carries a disease in it.
Other issues with immunizations were that they are ineffective with example quotes being:
. . . typically diseases and everything that multiplies quickly follows or surpasses human evolution. . . . the flu vaccination, you’re not likely fully protected because there’s so many different flus.
Finally, concern was voiced that immunizations might weaken the immune system of the child with an example quote being:
My biggest concern . . . it’s that I would be making the kid weaker if I gave him all of these immunizations rather than just let his body work it out on his own.
It should be noted that some participants voiced that they had no concerns regarding immunization of children.
Reasons for Not Immunizing Children
Although there were many concerns regarding immunization of children, the reasons for not immunizing children were much more concise (see Figure 2). Specific reasons include cost of immunizations, not valuing the importance of vaccinations, negative personal experience, issues with having time to take children to be immunized, religious reasons, and participants feeling like immunizations are unhealthy for the child.
Participant reasons for not immunizing children.
Current Plan for Immunization
Participants discussed their ideas regarding potential plans for immunization of future children (see Table 2). The majority of participants indicated that they would stay on a normal schedule for immunizations or maintain a normal immunization schedule but exercise caution with optional vaccines. Participants also reported that they would gather additional information prior to deciding how to move forward with a vaccination schedule. A small percentage indicated that they had no current plan for immunization of future children.
Current Plan for Immunization of Future Children (N = 29).
Information Regarding Immunizations
Given that some participants indicated they would gather additional information prior to making vaccination decisions, it is important to understand how information regarding immunizations is obtained. Participants indicated that parents find information through a variety of sources including family, the internet, doctors, other parents, television, educational pamphlets, and friends. Participants also discussed that the best way to receive information regarding vaccinations was from doctors. Furthermore, many participants explained that consulting multiple sources is the best way to receive information. One participant stated,
I feel like the best way to reach a conclusion about a vaccination, is to do a combination of all that we’ve talked about. Like contacting the CDC, asking your doctor, because . . . the doctor might not know all of the side effects.
Other best ways to find information included obtaining information from the internet, through research, from schools, and through the Centers for Disease Control and Prevention.
Discussion
The purpose of the current study was to better understand opinions and future decision making about immunizations among the upcoming generation of parents. This is of increased importance due to the amount of misinformation that is frequently cited in the literature and media regarding immunizations.29,30 The present study sought to gather information regarding prospective parental knowledge about diseases, opinions on immunizations, concerns about immunizing their future children, and where to obtain information on immunization.
Our results align with the Sturm et al 15 conceptual model illustrating the role of parental health beliefs when making immunization decisions for children. This model suggests that the interplay between personal/parental, institutional, and social/environmental factors, physical environment, and interface with health care influence parental vaccination decision making. Overall, the current study’s findings correspond with social/environmental and personal/parental components of Sturm and colleagues’ model. 15 Specifically, themes emerged suggesting that factors such as previous experiences with immunizations/side effects, perceived benefits and efficacy of vaccines, and beliefs about disease and immunization all influence decision making. These findings correspond with the major focus of Sturm et al 15 model on social-environmental (eg, attitudes and beliefs about disease and immunization) and personal factors (eg, perception of the efficacy of immunizations, health beliefs, etc).
Prior to asking participants directly about their feelings toward immunizations, participants were asked about their knowledge of common diseases or illnesses that could be prevented by vaccinations. Animal flus and polio were the 2 most frequently cited diseases. It should be noted that the mean age of focus group participants was relatively young (approximately 19 years old), therefore, it is likely that many participants may be less aware of diseases that have affected the United States historically such as yellow fever, typhoid fever, diphtheria, smallpox, and polio. Thus, it may be difficult to identify many deadly diseases/illnesses that once affected large portions of the population, but are now rarely encountered due to immunizations. This finding supports how the physical environment of health (ie, length of time since eradication) can affect vaccination decision making. 15
Participants also expressed an overall lack of concern about such diseases. Specifically, participants reported no concern or only slight concern about immunized diseases, likely due to decreased disease prevalence. Sturm and colleagues’ model 15 posits that prevalence rates may be positively related to vaccination uptake, such that when there are instances of high disease prevalence, parents are more likely to seek out vaccinations for their children.
It should be noted that most participants demonstrated a positive view toward immunizations in general. A number of individuals engaged in discussions about the need for additional information in this area. One developed theme was that additional research should be conducted on the impacts of each vaccine so that families could make more informed decisions. It appears that these participants valued research as an important consideration in their decision-making process. Thus, despite the mixed information presented in previous literature and in the media, participants acknowledged not only the importance of vaccinations in preventing disease but also the need for robust research to clarify this mixed information. Participants’ desire for additional research and accurate, easily accessible information impacts a number of components inherent in Sturm and colleagues’ model. Enhancing availability of vaccine information affects personal/parenting beliefs, and is largely affected by interface with health care providers (eg, discussions with physicians), social/environmental factors (eg, media coverage), and institutional policies (eg, professional group recommendations, provision of information through American Academy of Pediatrics, etc). This suggests the importance of making accurate vaccination information more readily available not only to parents, but to young adults contemplating parenthood.
While a large number of participants reported positive views toward immunizations, a smaller percentage questioned the need for immunization due to their perception that diseases have been eradicated. It may be that these participants are unaware of the influence of immunizations on disease eradication, in which case education regarding the affect and importance of immunizations is warranted. Additionally, participants identified concerns regarding immunizations such as sickness following vaccination and “catching” the disease that is being immunized due to the vaccination itself. One participant, for instance, discussed a fear of receiving the disease from the vaccine, stating, “. . . obviously immunization carries a disease in it.”
Discussions surrounding the ideas that all diseases have been eradicated and that receiving immunizations may result in contracting the disease to be vaccinated suggest the need for education on immunizations and the diseases they target. A common misconception about the flu shot, for instance, is that it contains the live virus, subsequently infecting those who received the shot with the flu. 31 Similarly, another misconception about immunizations is that they weaken the immune system, rather than strengthening it.32,33 Contrary to these beliefs, immunizations have been found to contribute to 2 to 3 million saved lives annually and are associated with many more benefits than costs. 2 Therefore, it is essential that this information be disseminated directly to consumers.
In terms of participant perception of how current parents obtain information regarding immunizations, it is clear that the most commonly reported way individuals receive information is through family, the internet, doctors, other parents, and friends. This information has strong implications on how researchers and policy makers work to disseminate educational information to the public. It is clear that information dissemination has to be multifaceted and focus on traditional methods through health care professionals (doctors) but also focus on a more general public approach to address information being spread through word of mouth (family, friends, other parents). With regard to the internet, data would suggest the importance of having high quality, easy to locate research presented at the appropriate reading level. Dissemination efforts should also focus on the findings that prospective parents plan to consult multiple sources in determining the best vaccination practices, with one of those sources often being physicians. This highlights the importance of implementing a multi-prong educational approach within the medical setting through training doctors to disseminate information orally, provide educational material, provide material with QR codes or URLs that lead to appropriate websites, and inquiring if parents need additional resources.
Study Limitations and Future Directions
While the present study provides a unique approach to understanding vaccine awareness among the upcoming generation of parents, it is not without limitations. The current sample for this study consists of prospective parents, rather than current parents. While our sample allows us to understand how to best educate and affect decision making regarding future vaccinations of young children, additional research is warranted to replicate this study with different samples. Given that the current study’s sample consisted of college students, many of the results regarding immunization knowledge and the value of research to better understand vaccinations’ impacts are likely due to increased education among participants. Thus, it would be interesting to determine if similar findings are yielded with a sample of individuals with lower education or with a wider age range. Additionally, future studies should include participants with and without children to compare outcomes on immunization decision making between each group.
Overall, the present study highlights the need for continued education on the accurate positive and negative effects of immunization and the diseases they target. The implications of these results on policy are multifaceted and include the importance of (1) disseminating vaccination education more widely to young adults, (2) enhancing consistency and trust between medical professionals and youth, (3) expanding public policy to aid in increased vaccine uptake, and (4) realizing individuals receive immunization information from a variety of sources and creating campaigns that reflect an array of evidence and informants. While education in this area is necessary and constructive, it is important to note that individual factors, including cultural and religious considerations, should be acknowledged and addressed when educating the public on immunization decision making. In the present sample, only a small percentage endorsed cultural or religious concerns regarding immunizations (2%-4%). However, when discussing immunization decision making with families, it is critical that an appropriate balance is adopted between healthy decision making and cultural respect. Taken together, provision of accurate, more easily accessible information regarding child immunizations while acknowledging associated individual and cultural factors will allow for a more informed decision-making process among upcoming parents.
Author Contributions
All authors contributed either to the conception or design of the study, analysis or acquistion of the data, and preparation of the manuscript.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.