Reasons for Non-Vaccination: Parental Vaccine Hesitancy and the Childhood Influenza Vaccination School Pilot Programme in England

"This study is a reminder of the importance of asking parents their reasons for non-vaccination to identify all reasons, including perhaps unexpected ones."

In 2013, the annual influenza immunisation programme in England was extended to children to reduce the burden of influenza, but uptake was sub-optimal at 53.2%. This qualitative study was undertaken to explore the reasons some parents decided not to vaccinate their child against influenza as part of the pilot programme offered in schools.

The Strategic Advisory Group of Experts (SAGE) on Immunisation's vaccine hesitancy working group has defined vaccine hesitancy as "a behaviour, influenced by a number of factors including issues of confidence (do not trust vaccine or provider), complacency (do not perceive a need for a vaccine, do not value the vaccine), and convenience (access)." The researchers explain that, because vaccine hesitancy is complex and context specific, it is vital to understand the reasons people are hesitant about receiving influenza vaccines across different contexts.

The study population consisted of parents in West Yorkshire and Greater Manchester who chose not to vaccinate their child against influenza in the school pilot programme in the 2014/15 season. Study data were collected through semi-structured interviews using an interview topic guide. In total, 1,223 invitation packs were sent to 913 parents; of the 138 who returned response forms, 25 of them were interviewed (two of whom had children in primary school and 23 of whom had children in secondary school).

The study highlighted a range of parental concerns and a lack of perceived need for the influenza vaccine for children. The main reasons given for the view that influenza vaccine was not needed for their children was that parents felt that their child was healthy, with a strong immune system, at low risk of catching influenza, that it is better to build their immune system with disease, and the view that if their child were to get influenza that their child would be at low risk of complications. Parents stated they would consider vaccinating their child in future years if they received feedback as to how the childhood vaccination programme had reduced the amount of influenza. Other parents wished to be told why their child's age group was being targeted.

Thirty-four percent of parents who did not consent to their child being vaccinated as part of the school programme had actually vaccinated their child elsewhere, intended to have their child vaccinated, or had not vaccinated them due to medical reasons (whether valid or perceived). This finding illustrates the importance of including additional questions or data sources when investigating under-vaccination.

Eleven parents interviewed declined the vaccine for religious reasons due to the presence of porcine gelatine in the vaccine. In 2001, the World Health Organization (WHO) convened a group of Islamic scholars, who issued a statement confirming that: "the transformation of pork products into gelatin alters them sufficiently to make it permissible for observant Muslims to receive vaccines containing pork gelatin and to take medicine packaged in gelatin capsules." Despite this statement, local concerns and hesitation have continued - such as in this study, which found that global statements, such as the one issued by WHO, reflecting the views of multiple Islamic scholars, did not change the minds of some who deferred to their local religious leader over global statements.

The researchers suggest that, although the findings are not generalisable, this study increases awareness of different perspectives and views and reasons for non-vaccination, and has informed future delivery and communication strategies in England. For example, the childhood influenza information leaflet was adapted and now includes an additional section on children who were vaccinated last year needing a vaccine this year (to raise awareness that the vaccination is annual), and the word 'pigs' is only referred to once in the new leaflet instead of twice.