Education about childhood vaccination is often misconstrued when not using the proper information containing evidence. Trustworthiness, safety, benefits and risks of vaccinations often come into discussion, and are sometimes not correctly answered. A large population of parents and care givers use improper information when making decisions about their children’s vaccinations; Delays and non-compliance often result. Proper formal education provided by health care providers helps, and is needed to enhance the likelihood of compliance of childhood vaccinations.
The adverse effects of childhood vaccinations have been primary drivers causing care givers when deciding if to comply or deny getting their children vaccinated. Parents’ fears and lack of reputable sources has been linked to the rise in unvaccinated children under 18. Evidence based research provides nurses and other health care providers with updated knowledge needed to educate caretakers, respond to questions, and also address fears about the safety and recommendations of childhood immunizations. Nursing research helps health care professionals: Advance patient outcomes, by educating the care givers of the advantages and effects of immunizations.
The PICO question addressed in this paper is: “In children, how are personal perceptions of parents’ regarding vaccinations compared to formal education from healthcare providers affect compliance with getting their children vaccinated?”.
P – Parents
I – Formal education
C – Personal education
O – Compliance of children receiving vaccines
Immunizations have become a controversial topic in the pediatric population. It is important that parents’ have the knowledge to make educated decisions about their child’s healthcare and treatments. Modern parents have easy access to the internet, this access gives parents the ability to search online resources concerning many topics concerning their children’s health. Many sources provide parents with biased or misleading information. The nurse advocates for the best care for a pediatric patient; and also respects the beliefs and concerns of the parent. One concern is parents’ refusing to have their children immunized. False information of childhood vaccines causing adverse reactions has been complicated this concern and led to the rise in unvaccinated children.
Nurses educate parents providing them with credible current information. This paper will discuss several articles that will provide information about: the availability of vaccines; the accessibility of vaccines; parents’ uncertainty of the safety of vaccines; and recommendations of primary providers for receiving vaccines.
The clinical issue of this paper is the validity and safety of children receiving vaccines; and their parents’ fears of adverse outcomes of their children receiving vaccines. As a future nurse, promotion of health and wellness will be a primary concern. Preventative health care concerns and providing patients and caregivers with information is an important part of nursing and primary care. Addressing concerns with factual information provides parents and patients with confidence to make educated decisions about the healthcare they receive.
Sources and Search Process
During the search of sources, a variety of factors were considered. The process started through Widener University’s Wolfgram Memorial Library database page. A search of data bases was done by title. “CINAHL (Nursing and Allied Health) with Full Text” was chosen. This option opened up a page to search through EBSCOhost. Three boxes were open for the search process to begin. In order to obtain the strongest sources, the PICO question was considered as a guide. Relevant words were thought of and tried as options to see if any results opened up that could back up this PICO question.
For the first article searched, the words “immunization”, “trends”, and “adolescent” were chosen. The option for editing the search was given to refine these results. Age of articles were chosen from 2011 through 2018. This was done so only modern information was available. The necessity for recent years’ information is because health care changes very much over a few years’ time; using old information could taint proper research when comparing it to the topic at hand. For the article’s language, English was chosen. The language is relevant so that it can be in the same language as this paper. Full text articles were also the only ones considered for the searches. The need for full text is to be able to read all of the article’s parts to be able to do a full appraisal on them. Once these were all set, the first search yielded 25 results. After considering all of the results, the article: “Trends in Michigan Early Adolescent Immunization: 2006-2008.” from was picked (Rees-Clayton, Montgomery, Enger, and Boulton, 2012).
For the second search, the CINAHL was also used. The same language and age of article parameters were used. Search words “hesitancy”, “vaccine”, and “parental” were used. These words that were searched had all of the main parts of the topic being researched. This yielded 33 results. The article “Parental hesitation in immunizing children in Utah” was relevant to this topic and was chosen (Luthy, Beckstrand, Callister, 2011).
The remaining searches were done using PubMed for the need of more refined results correlating to the topic being researched. Widener University’s Wolfgram Library database was still being used as the search engine. Article age, the need for full text articles, and the English language were done for these as well. The words searched were “vaccination”, “confidence”, and “refusal”. The amount of results obtained were 52. From all of those articles, “Vaccination Confidence and Parental Refusal/Delay of Early Childhood Vaccines” was most relevant to this paper (Gilkey, Magnus, Reiter, Dempsey, and Brewer, 2016).
A second search was done using PubMed and the same search parameters, using the words “parental”, “hesitancy”, and “influenza”. For this search, a specific word such as influenza was used to obtain more specific and various articles. Having this advanced search was useful for this particular topic. It yielded 20 articles, and the one used was “Parental vaccine hesitancy and acceptance of seasonal influenza vaccine in the pediatric emergency department.” (Strelitz et al., 2015).
Lastly, a search using the above search engine and parameters was done. The words that were used were “hesitancy”, “vaccine”, and “practitioners”, yielding 25 results. After analyzing each of them, “Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France” from 2015 found to be the best fitting (Verger et al.,). This search was done with the word practitioner to add an additional factor into the results.
Appraisal of the Evidence
A study was conducted by Gilkey et al. (2016). The purpose of this study was to provide evidence to address apprehensions and pauses of caregivers in allowing their children to get their scheduled immunizations (Gilkey et al., 2016). Data was collected from a large, population-based sample of parents in the US. This study was done to validate the “Vaccination Confidence Scale”, a survey created for this study (Gilkey et al. 2016).
The study conducted by Luthy (2011) had a purpose of why the care takers in the state of Utah delayed their children being vaccinated. Data was compiled using a survey asking parents why they hesitated to get their children vaccinated, and other questions and concerns they may have had.
A study conducted by Rees-Clayton et al. (2012) was to determine how many adolescents living in Michigan received recommended scheduled immunizations between 2006 and 2008.
A study conducted by Strelitz et al. (2015) was done to attain scores about parents’ point of view about childhood vaccines. The data gathered measured parents’ attitudes about their children receiving the flu vaccine in the pediatric emergency department (ED). The study was used to determine if the parents’ scores were related to their children receiving the flu vaccine while in the pediatric ED.
The purpose of the final study conducted by Verger (2015) was to done determine: The frequency that providers hesitated the recommended vaccines to patients, and what factors that influenced providers’ recommendations.
Research Design, methods, and data collection
Gilkey et al. (2016) used stratified sampling method. Data was gathered from 9,354 parents who took the National Immunization Survey (2011). This survey had parents report the vaccination history and vaccination status of recommended vaccinations of their 19 through 35-month-old children. A regression model using multiple variables was used to measure associations between the average parents’ scores on the ”8-item Vaccination Confidence Scale”; parents’ refusal of vaccines, and any vaccination pause (Gilkey et al., 2016).
Rees-Clayton et al. (2012) gathered vaccination data from the Michigan Care Improvement Registry (MCIR), the registry for Michigan state immunization data base. The study included more than 57 million vaccines documented in the MCIR. The 3 groups in this study of 11 through 12-year-old adolescents were used to assess immunization coverage, time, trends, similarities and differences of the children who were immunized, any funding, and the locations of the vaccines.
Locations (Rees-Clayton et al., 2012).
Strelitz et al. (2015) conducted a cross-sectional study during the 2013 – 2014 flu season in the Pediatric Emergency Department setting. Verger (2015) also conducted a cross-sectional observational study in 2014. Verger (2015) randomly chose 1712 randomly privately practicing French general practitioners. This study used a score consisting of self-reported recommendations and frequency for 6 specific vaccines in target populations (Verger, 2015). Luthy (2011) conducted a cross-sectional study as well in 2011. It measured 86 responses from care takers whose children did not have all of the recommended immunizations.
Samples, populations, and settings
The study conducted by Gilkey et al. (2016) contained the following sample: 53% boys and 47% girls. The demographics of the children included in the study were: 61% white non-Hispanic, 14% non-Hispanic black, or 15% Hispanic children (Gilkey et al., 2016). Forty-five percent of the children were eligible for the program “Vaccines for Children” Gilkey et al, 2016). Female parents or guardians made up 78% of the sample (Gilkey et al., 2016). Caregivers that have at least a high school education made up 39% of the sample, and those living below the poverty line made up 29% of the sample (Gilkey et al, 2016).
The study compiled by Luthy (2011) consisted of 86 reactions from parents and care givers of children from birth up to 18 years of age. A convenience scale was used. The demographics were 39% boys and 61% girls.
The Rees-Clayton et al. (2012) sample included 3 overlapping cohorts of Michigan children ages 11 or 12 years. The time frames used in this study included: December 1, 2006, December 1, 2007, and December 1, 2008 (Rees-Clayton et al., 2012). The date used in the study was December 1, because most Michigan children are eligible to start kindergarten by this date, making the age of most sixth graders between 11-12 years old (Rees-Clayton et al., 2012).
Strelitz et al. (2015) used the following sample: non-Hispanic White race parents 53%; >30 years of age 68%; married parents 71%; and parents that had some college or higher 75%; those with a household income of $75,000 or less 65%; fewer than half, 49% had insurance through the government.
Verger (2015) used random sampling selected by: age < 50, 50–58, > 58 years old, the number of office consults, and the number of house calls made per year. This data obtained from a National Insurance database (this database provided the general practitioners reimbursement information); and other sample considerations included: city where the practice was located (Verger, 2015). The sample size included at least 10 general nurse practitioners. The practitioners used in this study participated and responded to a cross-sectional survey conducted every six months for two and a half years (Verger, 2015).
A small group of parents reported: 15% refused vaccines and 27% delayed getting their children vaccinated (Gilkey et al, 2016). Parental confidence in vaccinations showed negative impact and was related to parental refusal of MMR, varicella, and influenza vaccines (Gilkey et al., 2016). A negative association between vaccination confidence and vaccination pauses (Gilkey et al., 2016). When parents were confident in vaccination confidence more children received the following vaccines: MMR, varicella, and influenza vaccines (Gilkey et al., 2016).
A significantly large margin of care takers from the Luthy (2011) study had two themes in common: that there was a need for strict vaccinations, and the apprehension of their children acquiring adverse effects from receiving vaccinations- including autism.
The Rees-Clayton et al. (2012) study showed an advancing number of immunizations done between 2006 and 2008, mostly in the summer. Over half of children studied received one or more vaccines at the same time (Rees-Clayton et al., 2012). The study showed older children with government insurance were more likely to receive all early childhood vaccinations (Rees-Clayton et al., 2012).
The Strelitz et al. (2015) study included 152 parents. The survey took 7minutes with average score of 28 (74% scoring =50 were more likely to refuse the flu vaccine (Strelitz et al., 2015).
Verger (2015) reported Primary providers that 16% – 43% never or seldom recommended vaccines to their patients. These PCPs frequently recommended vaccines if they were comfortable educating parents on the benefits and risks of vaccines (Verger, 2015). PCPs who trusted the available sources of information highly recommended vaccines (Verger, 2015); and PCPs who considered increased risk of adverse effects or the effectiveness of vaccines did not recommend vaccines were not recommended (Verger, 2015).
Limitations: cross-sectional design was limited, because the researchers had trouble with finding the correlational direction regarding caregivers’ trust relating to their compliance of getting their children vaccinated (Gilkey et al., 2016).
Limitations noted in Luthy (2011) study were the locations where the data for this study was conducted. Considering it was only done in the state of Utah, this limits how similar research would end in other states.
The study by Rees-Clayton et al. (2012): limitations in this study were the location where the vaccines were given. Some children may have been vaccinated at a pharmacies or emergency departments, rather than by a Michigan provider (Rees-Clayton et al., 2012). Rees-Clayton et al. (2012) estimated that the number of teens vaccinated in these alternate settings; they believed this number to be small and had minimal effects on the findings.
The Strelitz et al. (2015) study was limited because the study was only done during the flu season, and the actual vaccine was available for some time before the flu season started. The actual number of compliant parents may have been greater, because more parents could have given consent to this vaccination prior to the beginning of the study and could have been involved in the study.
Limitations noted in Verger (2015) study were: the behaviors regarding vaccine recommendations of the health care providers were reported by personal experience, and may include biased factors.
The overall consensus from these articles show that a care givers lack of proper knowledge regarding vaccinations hinders overall compliance of children receiving proper timely immunizations. Trust of vaccinations greatly affected parent feelings towards whether or not to immunize their children. Reviewing these articles teaches a need for a change of practice is warranted: a required set of resources for the care givers. Care givers everywhere need a better education from their health care providers regarding the need for timely, thorough vaccinations.
The negative results that many children do not get vaccinated, or get a delay in vaccination spans from lack of proper education from health care providers. The surveys and studies done show a negative impact of health care providers not giving care givers strong evidence of the level of need of immunizations. Care givers go into appointments with knowledge imbedded from the internet, friends, and family members. This information is often negative, false, and does not use evidence.
A change of practice should be for every health care provider to mandated to provide evidence of the need for vaccines, and the effects of vaccines not given. Research also provided evidence that many health care providers were not prepared to discuss the advantages and effects of vaccines because of the possibility of backlash and negative remarks by the parents. This would be prevented by this information being mandatory, whether the care givers asked for it or not. Other resources should include optional classes for care takers to take to learn about these issues and others.
Often times, insurance and prices of such necessities and luxuries may be the burden; a change in practice should be to include these classes in the price of a doctor’s visit. In the research, the parents who were provided evidence from health care providers regarding information about vaccines, had more parents deciding to vaccinate their children.
Reviewing the PICO question, “In children, how are personal perceptions of parents’ regarding vaccinations compared to formal education from healthcare providers affect compliance with getting their children vaccinated?”, there is a strong connection with the clinical issue in question: “The validity, need, and safety of children receiving vaccinations in relation to their parents’ and care givers’ fears of adverse outcomes of their children receiving vaccines”. A push for proper parent education regarding the advantages and effects of vaccinations is needed and currently lacking. Care givers’ perceptions of lack of safety in childhood vaccines outweighing the effects of their children not receiving these vaccines is strong.
Health care providers need to keep up to date on current evidence based studies and research in order to provide the necessary information to parents regarding immunizations. The imminent threat of dangerous diseases and viruses coming back into society is there, widely from individuals not vaccinating their children. This information needs to be relayed to care givers of children. Providing proper education and knowledge can lessen false and negative information that will provide parents the chance to be at ease when deciding to immunize their children.