ANALYSIS | Unpacking parents’ reasons for not vaccinating their children: Why it matters

For many of us, the case for childhood vaccination seems self-evident. Every year, this powerful public health intervention protects billions of children from deadly and debilitating infections such as polio and measles. Yet worldwide, many parents are reluctant — if not outright refusing — to vaccinate their children.

This includes parents who have access to vaccines, are well-educated and have enjoyed the benefits of having their children grow up in a world free of many vaccine-preventable diseases.

This phenomenon is referred to as vaccine hesitancy, and it’s not new. Public concerns about vaccination, and controversies surrounding it, are as old as vaccines themselves. Yet with the recent global outbreaks of diseases such as measles and diphtheria, and more recently Covid-19, vaccine hesitancy has been placed firmly on the global public health agenda.

In a recently conducted Cochrane review we analysed qualitative studies of parents’ views, experiences and practices about routine childhood vaccination.

We included 27 studies in our analysis. Studies were conducted in Africa, the Americas, Southeast Asia, Europe and the Western Pacific, and included urban and rural areas and high-, middle-, and low-income settings.

We found vaccination uptake, as with many health interventions, is influenced by several factors and carries different meanings — social, political, economic, ideological, moral and biological. Through their vaccination choices, parents are often communicating not just what they think about vaccines, but also who they are, what they value and with whom they identify.

We found parents’ vaccination views and practices are shaped by factors including:

• their broader worldviews surrounding health and illness;

• the vaccination ideas and practices of their social networks;

• wider political issues and relations of power, and particularly the impact these have on parents’ trust (or distrust) in those associated with vaccination programmes; and 

• access to and experiences of vaccination services and their frontline healthcare workers.

Our findings suggest childhood vaccination, whatever stance is taken, is a complex social process. It is deeply embedded in the wider social worlds in which people live. Understanding these social worlds, and placing them at the centre of public health interventions, is critical.

Reasons for vaccine hesitancy

Vaccine hesitancy is not a single problem. The way it manifests and why it occurs differs considerably across place and time and even vaccines. Local contexts and framing matter. Yet we found certain overarching patterns across the studies that help to explain why parents may be hesitant about routine vaccines for their children.

The first reason relates to the view that healthcare is a matter of personal risk, choice and responsibility. Many parents, across the spectrum of vaccination attitudes, hold this worldview. Yet some parents see this worldview as being in conflict with vaccination promotion messages. These messages emphasise population-level risk and community health. This perceived tension may lead some parents to be hesitant about vaccination for their children.

The second reason relates to the impact of social exclusion. Exclusion can take many different forms: economic, political  and cultural. All these forms can lay the foundation for distrust, alienation, resentment and demotivation. Parents who are socially excluded may be hesitant about vaccination because they distrust vaccines and those delivering them. Or it may be a form of resistance or a mechanism to bring about change. It may be that vaccination takes time and comes with opportunity costs for these parents.

Alternative approach

Parents who resist vaccines for their children are commonly portrayed as “ignorant”, “misinformed”, “irrational”, “selfish” or “evil”. It is often assumed the attitudes of these parents can be corrected with biomedical education and advanced risk communication strategies. The findings from our review suggest a more nuanced and less clinically oriented approach may be needed.

Such an approach involves taking seriously, on their own terms, the complex factors and meanings shaping parents’ vaccination choices. It means recognising that parents’ values and priorities, and their responses to these, do not always align with the goals of vaccination programmes.

“Hesitancy” does not only have negative connotations, as seminal work published over two decades ago demonstrated. In fact, for many parents, “hesitancy” may also be about striving for or desiring something: to protect their child’s health; to be part of healthcare decision-making; to belong and feel included among peers; to feel confident that expert systems have their best interests at heart; to have their own priorities recognised and basic needs met.

Approaching hesitancy with this understanding is unlikely to translate into one-dimensional and “quick-fix” interventions. Yet we believe it could provide avenues for the development of more sensitive and effective strategies for engaging with parents who decide against vaccination for their children.

About the authors:

• Sara Cooper: senior scientist, Cochrane SA, SA Medical Research Council (SAMRC) and honorary researcher, division of social & behavioural sciences, School of Public Health, University of Cape Town (UCT)
• Alison Swartz: UCT
• Bey-Marrié Schmidt: senior lecturer, University of the Western Cape
• Charles Shey Wiysonge: director, Cochrane SA, SAMRC
• Christopher J Colvin: associate professor, UCT
• Evanson Z Sambala: research fellow, School of Public Health, University of the Witwatersrand
• Natalie Leon: specialist scientist researcher, SAMRC

This article was first published by The Conversation.