Parental Beliefs and Decision Making About Child and Adolescent Immunization: From Polio to Sexually Transmitted Infections

This 20-page article presents a review of research on the role of United States (US) parental attitudes and beliefs in decision making about child and adolescent immunisation. It describes the historical context of vaccine-related decision making research. The potential influences on vaccine decision making studied are social-environmental and parent-specific personal factors. Social-environmental issues discussed include media coverage of vaccines, perceived social norms, and the persuasive influence of peer groups. Personal factors addressed include parental health beliefs, attitudes, and knowledge related to vaccine preventable diseases and immunisation, as well as elements of the decision making process. The influence of healthcare providers is used as an example of the family's interface with the healthcare system.

In analysing the role of media coverage, authors found that analysis-based studies of media coverage of vaccination rhetoric and persuasive themes has been conducted only in English-speaking countries. Also the causal role of media in opinion-shaping on the topic of immunisation has not been widely tested. Those examples given by the authors showed a correlation between positive press and higher vaccine uptake and negative press and a drop off in uptake.

The influence of social group norms is reviewed in studies using the health belief model (HBM), the theory of reasoned action, the theory of planned behaviour, and the protection motivation theory, all of which include social norms as potent influences on decision making. Factors found to be present and influential in parental decision making were "felt pressure" to accept or decline based on social group opinion (sometimes called "bandwagoning") and health care provider attitudes and recommendations. Parental attitudes are cited as being a strong factor, though less strong in some studies, than financial and structural barriers to receiving immunisations, and less predictive than sociodemographics.


The authors discuss the problematic nature of gathering attitudinal information from parents and various factors that may contribute to the complexity of opinion-shaping. In part, a more complex selection of vaccines is being recommended for childhood use. This presents, in the minds of some parents, a contrast to a health environment in many communities in the US of lower disease incidence, particularly early childhood diseases. The authors find that parental beliefs and worry regarding potential side effects of vaccines have emerged as important determinants and are found to erode uptake, particularly after a "vaccine scare". Groups surveyed after drops in coverage of two different vaccines, polio and MMR [measles, mumps, rubella), were found to have the same anxieties about possible health impairments, "as well as concerns about the conflict between societal benefits of immunization and parental rights to decide on behalf of their individual child. Parents were generally dissatisfied with the communication process with their health care providers."

As indicated by the authors, because of the "widely acknowledged tension between public health programs... and individual parent rights to make decisions about their child's health care and to accept or reject childhood immunization," the route of empowering parents "to conduct a thoughtful consideration of evidence-based information that is presented by health care providers in a manner that they find useful (e.g., risk and benefit information that is understandable)," will likely positively affect overall rates of immunisation. The authors found that 40 percent of vaccine providers did not discuss vaccine risks and benefits with parents, and concluded that where practitioners are not comfortable with the topics, communication skills about risks and benefits can be improved.

In conclusion, the article suggests that when parents contest the need for or safety of vaccines for children, practitioners may find it productive to open a discussion with parents on their concerns about immunisation. Research cited suggests empathetic and empowering approaches to parental decision making. It might also be advantageous, according to authors, to inquire into cultural, religious, and personal history issues that contribute to their uncertainty. In addition, as stated here, "practitioners should not allow written materials (i.e., vaccine information sheets) to take the place of face-to-face conversation between parent and provider." Because of the number of new vaccines becoming available, providers may need to educate parents and adolescents (in the case of new STI immunisations) on the concept of "attributable risk" and may want to guide them on how to evaluate health-related information encountered in the media and on the internet.

For a copy of this article, please contact Lynne A. Sturm through the contact information below.