Parental refusal of vaccines is a growing a concern for the increased occurrence of vaccine preventable diseases in children. A number of studies have looked into the reasons that parents refuse, delay, or are hesitant to vaccinate their child(ren). These reasons vary widely between parents, but they can be encompassed in 4 overarching categories. The 4 categories are religious reasons, personal beliefs or philosophical reasons, safety concerns, and a desire for more information from healthcare providers. Parental concerns about vaccines in each category lead to a wide spectrum of decisions varying from parents completely refusing all vaccinations to only delaying vaccinations so that they are more spread out. A large subset of parents admits to having concerns and questions about childhood vaccinations. For this reason, it can be helpful for pharmacists and other healthcare providers to understand the cited reasons for hesitancy so they are better prepared to educate their patients' families. Education is a key player in equipping parents with the necessary information so that they can make responsible immunization decisions for their children.

“Vaccine hesitancy” is a relatively new term used in research over the past few years to describe anyone who is doubtful about vaccinations or who chooses to delay or refuse immunizations even when they are readily available.1,2 Vaccines play a vital role in preventing diseases in children, so it is crucial that pharmacists and other healthcare professionals understand the reasons that parents are hesitant or refuse to vaccinate their children. Although there are no federal laws regarding vaccine administration, each state has laws in place dictating which vaccinations are required for children prior to entering schools.3 All 50 states allow medical exemptions for certain patients, such as those who are immune compromised or allergic to various vaccine components. Additionally, there are 30 states that allow exemptions for children whose parents cite religious reasons and 18 states that make special accommodations for those expressing philosophical reasons.3 States that have more lenient laws on vaccination requirements also have an increased rate of exemptions granted; this can lead to greater vulnerability in the population in terms of contracting preventable diseases.4 

There have been a number of studies examining the reasons why parents refuse, delay, or are hesitant to vaccinate their children (Table). In one such study,5 77% of parents polled reported having concerns about one or more childhood vaccinations. Reasons expressed by parents vary widely but can be classified into 4 overarching categories. These categories are religious reasons, personal beliefs or philosophical reasons, safety concerns, and a desire for more information from healthcare providers. The purpose of this article is to equip pharmacists and other healthcare providers with an understanding of the most heavily cited reasons that influence parents not to vaccinate their children. This will better enable healthcare personnel to provide the education and awareness that patients' families need to make responsible immunization choices.

Table.

Review of Selected Literature

Review of Selected Literature
Review of Selected Literature
Table.

Review of Selected Literature (cont.)

Review of Selected Literature (cont.)
Review of Selected Literature (cont.)

Within each of the categories described above parents present a spectrum of compliance with vaccination, including delaying vaccinations, only refusing certain ones, or refusing immunizations completely. Religious reasons tend to account for the majority of total vaccine refusal, while parents with personal beliefs against immunization tend to be more willing to compromise and at least partially vaccinate their children. Parents are concerned with doing the best for their children, and hearing reports of potential safety issues or that childhood diseases are not a large threat can hinder them from vaccinating their children.

Religious Reasons

One of the most common reasons parents offer for choosing not to vaccinate their children stems from their religious beliefs. With only 4 states not offering exemptions to families for this reason, it poses a major obstacle to those seeking to increase childhood vaccination rates.3 Religious reasons are distinct from other cited reasons in that they are generally linked to the core beliefs of the parents, and it is very difficult to dissuade these individuals from views against immunization. These choices are not the by-product of ignorance but rather the intentional and calculated decision related to a staunch conviction. In addition, in contrast to other cited reasons for hesitancy, those driven by religious assertions most often are linked to a complete refusal of all vaccines.2 

Imdad et al6 conducted a study in New York State and found that the rate of school vaccination exemptions due to religious reasons between 2000 and 2011 increased sharply. In response to this reality, lawmakers put in place guidelines that introduced requirements that mandated that in order for schools to grant religious exemptions, the parents had to demonstrate their “genuine and sincere religious belief” that contradicted the use of vaccinations.6 These burdens of proof are likely to become more popular as an increasing number of parents attempt to use the nebulous loophole of religious freedom to bypass the societal necessity of combating preventable diseases through immunizations. The authors6 further discovered that the counties that had higher exemption rates, ≥ 1%, also had an increase in reported pertussis cases, 33 per 100,000 compared to 20 per 100,000 in counties with lower exemption rates.

Wombwell et al7 evaluated different religions and the reasons that vaccines may violate their religious tenets. The explanation most commonly offered for why specific vaccinations oppose religious tenets involves components of the vaccines.7 The animal-derived gelatin used in producing some vaccines as well as the human fetus tissue used in the rubella component pose the largest concerns.7 By understanding the objections that large portions of the population hold, monies may be strategically targeted for research that can address these concerns and render vaccinations more acceptable for these groups.

Personal Beliefs or Philosophical Reasons

Another common reason that parents give for refusing or delaying vaccinating their children is personal or philosophical reasons. Although only a handful of states allow exemptions for this cause, it must be carefully studied, as it may present opportunities for practitioners to enlighten parents regarding the urgency of protecting the children through preventive measures. Though it seems contrary to human intuition, there is a group of people who see some benefit in having their children contract certain preventable diseases.8 Some parents believe that natural immunity is better for their children than is immunity acquired through vaccinations.8 Others express the belief that if their child contracts a preventable disease, it will be beneficial for the child in the long term, as it will help make the child's immune system stronger as he grows into adulthood.8–10 Some parents believe that the diseases for which we vaccinate are not very prevalent so their children are at minimal risk of contracting these diseases. For this reason, they also believe that the possible negative side effects of vaccine administration outweigh the benefits of the vaccines.9 Many parents do not see the preventable diseases as serious or life-threatening and would prefer to not put extra chemicals into their children's bodies.8,9 Other parents think if their children have healthy diets and lifestyles they are at a decreased risk of contracting preventable childhood diseases. They also are under the assumption that if they were to contract one of the diseases that it would be easily treatable.10 

Safety Concerns

A third, and potentially the greatest, reason parents express for refusing vaccinations for their children are concerns about the safety of vaccines. Most of these concerns are based on information these parents have discovered in the media or received from acquaintances. Regardless of whether the stories stem from television, the Internet, radio, or from family and friends, parents are constantly bombarded with other peoples' opinions about vaccinations.2,8,10 All of this information can be overwhelming for some parents to sift through, making it difficult for them to make their own well-informed decision.8,10 Many of the reports and opinions that bombard parents and cause uncertainty are targeted at the safety of vaccines. They raise doubts about both short-term adverse reactions and the possibility of long-lasting negative effects.2,5,9,10 It is these concerns about safety that can cause parents to completely refuse vaccines.

Fredrickson et al8 found that the most commonly reported reason parents had for refusing one or more vaccines was other people or media reports. Stories in the popular media, such as social media and large-scale news outlets, are often sensationalized to elicit higher ratings and oftentimes spotlight a rare incident in which a child suffers as a result of an unforeseen side effect of a vaccine. Media that cite problems with components of vaccines (such as thimerosal) and report that vaccines can cause autism, brain damage, or behavioral problems cause parents to be more cautious and have more concerns regarding the safety of vaccines.2,5,8–10 Thimerosal, however, has been removed from those vaccines intended for children under 6 years of age for over a decade now.11 Accounts noting these rare occurrences breed fear in the hearts and minds of parents, who overestimate the dangers associated with vaccinations. Some fearful parents balk at the timing of immunizations. Fear can influence some parents to choose to delay vaccines so their child does not receive more than one vaccine at a time.9 They fear that simultaneously administering multiple vaccines may overload their child's immune system, and they think that allowing all of the vaccinations to occur according to the recommended schedule will make the safety risk greater. As a result of this logic, many choose to delay vaccines in order to better protect their children.9,10,12,13 While some may view this as a missed opportunity, others believe that a delayed vaccination schedule is superior to not receiving vaccinations at all. Many parents believe the side effects of vaccines are more extensive than what they are told by their physicians and that the risks outweigh the benefits of vaccinating their children.9,10 Healthy relationships between a practitioner and parent can go a long way toward helping patients in terms of this concern. Trust is paramount and will help put parents at ease and help them overcome unmerited fears.

Desire for Additional Education

The fourth common thread is that parents want more information regarding vaccinations. They want to be able to make informed decisions about their child's healthcare by knowing both the benefits and risks associated with each vaccine.9,10,14 In a study conducted by Gust et al,14 approximately one-third of parents indicated that they did not have enough access to sufficient information, and the majority of those parents did not think their child's provider was easy to talk to. Many parents desire to have more detailed information regarding the side effects and benefits associated with vaccines expressed in a factual way that does not appear to be trying to sway them one way or the other regarding vaccinating their child.8,10 

A vital role pharmacists and other healthcare providers can play would involve the provision of unbiased, factual information relating to vaccines as well as the discussion of these materials with the parents.1 There are a number of resources online, including the Centers for Disease Control and Prevention and American Academy of Pediatrics Web sites, as well as print resources that can be provided to parents. Parents want to be able to have open conversations with their child's healthcare provider in which they do not feel judged or attacked.2,8,9 Parents would like to have the freedom to be able to ask questions without judgment. Physicians are one of the most important sources of information for parents who are making decisions about their children's healthcare.2,8,10 In a study conducted by Kennedy et al12 noted that 81.7% of parents said their child's healthcare provider was one of the most important sources of information. When parents do not get the information they want from their providers they seek information from other sources that can potentially mislead and misinform them, causing them to make poor choices for their children.8,10 

If pharmacists and other healthcare providers are able to understand the main concerns parents have about vaccinating their children, they can be better prepared to have informative conversations about immunizations. They will also be able to provide the information parents need to make the best-informed decisions for their children. Parents who are hesitant to vaccinate or who refuse vaccines care about their children and want to do what they can to protect them, just like any other parent. It is important for practitioners to have open and frank conversations with their patients and their families so that the families will understand the benefits of vaccination without feeling attacked or judged for having questions about their child's healthcare.5,8,9 

Education and taking time with patients have been shown to result in modest improvement in terms of affecting parents' attitudes about immunization, but the exact messages or tools for healthcare providers should use have not been fully discovered.15 Understanding the source of parents' questions can equip pharmacists, physicians, nurses, and other healthcare providers to speak with patients on a more relatable level and to speak to the areas parents value the most. All healthcare workers should make an effort to stay up to date on the recommended vaccines and to understand why those immunizations are recommended. This information will allow patients to have face-to-face access to reliable information that can help them to make the best decisions for their families. Additional research aimed at evaluating how practitioners can better provide information to parents to help them see the importance and benefits of vaccinations needs to be conducted.

At the time of publication, Kristin Bohannon was a Doctor of Pharmacy candidate at Texas Tech University Health Sciences Center School of Pharmacy, Abilene, Texas.

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Disclosures The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.