Critical Analysis: Coercive vs Supportive Strategies to Improve Vaccination Rates

This critical analysis explores the attitudes of parents towards child vaccination and examines the barriers and strategies for improving vaccination rates. Themes include parental attitudes, barriers, and strategies for vaccination.

CRITICAL ANALYSIS-
COERCIVE V/S
SUPPORTIVE
STRATEGIES TO
IMPROVE VACCINATION
RATES

Table of Contents
INTRODUCTION...........................................................................................................................3
APPENDIX......................................................................................................................................3
CRITICAL ANALYSIS................................................................................................................12
Theme 1: Attitude of parents towards child vaccination...........................................................12
Theme 2: Barriers to childhood vaccination..............................................................................14
Theme 3: Strategies for vaccination..........................................................................................15
CONCLUSION..............................................................................................................................16
REFERENCES................................................................................................................................1

INTRODUCTION
Vaccination amongst the children is an extremely critical issue and needs to be followed
by parents mandatorily so that a child can be protected from fighting diseases that they might
contact with in future. In this report a critical evaluation has been done on six articles that discuss
various aspects of the parent’s role in getting the child vaccinated. This report will also highlight
the various themes important for conducting the critical analysis effectively in highlighting the
importance of child vaccination.
APPENDIX
APA citation
Bianco, A., Mascaro, V., Zucco, R., & Pavia, M. (2019). Parent perspectives on childhood vaccination: How
to deal with vaccine hesitancy and refusal?. Vaccine, 37(7). 984-990.
Step 1. Consider the research hypothesis
What are parents perspectives on childhood vaccination.
Step 2. Consider the study design
Cross sectional study
Use of PACV survey
Step 3. Consider the outcome variable
Yes in quantitative manner.
Parental attitudes were measured using the Parent Attitudes about Childhood Vaccines (PACV)
survey, to screen for Vaccine Hesitancy (VH). In addition, selected factors have been grouped in three
categories (contextual, individual and group and vaccine/vaccination-specific influences), and were
explored as potential determinant of VH and vaccination refusal or delay
Step 4. Consider the exposure(s)
Parents

Yes. Kindergarten parents.
Step 5. Consider the methods of analysis
PACV and VHP analysis
NO
Step 6. Consider the potential sources of bias (systematic errors)
No biasness.
The current measurementis appropiriate.
Step 7. Consider the interpretation of results
7.7% of subjects were defined as VH parents (VHPs) through PACV score, while 24.6% reported
having refused or delayed at least one dose of vaccine for their child. VH was more common in those
parents that decided not to vaccinate their child after having received information from mass-media,
in those who did not agree with mandatory vaccinations, and in those who agreed with political leaders
who oppose to vaccination. Vaccine refusing/delaying parents were more frequently those who agreed
that infant vaccinations are primarily an economic business of pharmaceutical companies, and who
disagreed that access to the kindergarten should only be allowed to children who had been vaccinated.
Step 8. Consider how the results of the study can be used in practice
Yes, they are consistent.
The findings of the present study emphasize the importance of PACV as a tool to screen VHPs.
Furthermore, results highlight important potential determinants of VH, such as communication and
media environment, and attitudes about prevention.
Health care providers could act as key components to improve the public trust to scientific and
epidemiological evidence.
APA citation
Makarić, Z. L., Kolarić, B., Tomljenović, M., & Posavec, M. (2018). Attitudes and beliefs related to

childhood vaccinations among parents of 6 years old children in Zagreb, Croatia. Vaccine, 36(49). 7530-
7535.
Step 1. Consider the research hypothesis
What are the Attitudes and beliefs related to childhood vaccinations among parents of 6 years old
children in Zagreb, Croatia.
Step 2. Consider the study design
descriptive
Questionnaire methods
Step 3. Consider the outcome variable
In the quantitative manner
Self administered questionnaire and cluster sampling
Step 4. Consider the exposure(s)
parents of 6-years-old children in Zagreb
Self administered questionnaire
Step 5. Consider the methods of analysis
Croatian Immunization Programme
Yes
Step 6. Consider the potential sources of bias (systematic errors)
Limited to Croatia
NO measurement biasness

Step 7. Consider the interpretation of results
In total 542 questionnaires were collected, 80% (n = 430/542) of respondents were mothers. Even
though 72.6% (n = 385/531; 95%CI: 69-76) respondents feel that childhood vaccination should remain
mandatory, 36.3% (n = 192/528; 95%CI: 58.3-65.3) considered that simultaneous administration of
vaccines can have negative effect to their child's health. In addition, 38% (n = 202/532; 95%CI: 33.2-
43.1%) feared that vaccines may harm their child. Of total, parents mostly reported positive attitude
towards vaccination (61.8%; 95% CI: 34.7-42).
Step 8. Consider how the results of the study can be used in practice
Parents with positive attitudes were more likely to state their child experienced mild or no adverse
reaction after vaccination, report not delaying vaccination and provide additional non-mandatory
vaccines to their child (p < 0.05).
Gender, age, education and marital status of parent were not significantly associated with the positive
attitude towards vaccination.
need for educational interventions and communication strategies that could foster better knowledge on
immunization with a focus on parental misconceptions, perceived constraints and safety issues about
vaccine.
APA citation
Jeong, Y. W., Park, B. H., Kim, K. H., Han, Y. R., Go, U. Y., Choi, W. S., ... & Park, H. (2011). Timeliness
of MMR vaccination and barriers to vaccination in preschool children. Epidemiology & Infection, 139(2).
247-256.
Step 1. Consider the research hypothesis
Timeliness of MMR vaccination and barriers to vaccination in preschool children of Korea
Step 2. Consider the study design
Observational
Using questionnaire method

Step 3. Consider the outcome variable
Yes, in a quantitative manner.
Have the authors always accurately assigned people as having the outcome (or not)? What was the
method of data collection, and how might this have affected accuracy?
Step 4. Consider the exposure(s)
Children aged 15-23 months and 4-6 years
Yes, survey was the method.
Step 5. Consider the methods of analysis
vaccine coverage rate of measles-mumps-rubella (MMR) vaccination
no
Step 6. Consider the potential sources of bias (systematic errors)
Limited to Korean children
No measurement bias
Step 7. Consider the interpretation of results
Being unaware of the necessity for vaccination and its schedule, child being sick during the
recommended vaccination period, and recommended vaccination period not being over were
significant preventive factors to timely vaccination (P < 0·05).
Step 8. Consider how the results of the study can be used in practice
Yes
Using primary sources
Children with working mothers, single parents, those not being cared for by their parents, and those

younger among siblings were at a higher risk of not being vaccinated on time. In order to increase
timely vaccination, accurate information should be delivered and a systematic approach should be
targeted to high-risk groups.
APA citation
Lawrence, G. L., MacIntyre, C. R., Hull, B. P., & McIntyre, P. B. (2004). Effectiveness of the linkage of
child care and maternity payments to childhood immunisation. Vaccine, 22(17-18). 2345-2350.
Step 1. Consider the research hypothesis
Effectiveness of the linkage of child care and maternity payments to childhood immunisation
Step 2. Consider the study design
Observational
Case study analysis
Step 3. Consider the outcome variable
Yes, in a quantifiable way.
Yes, case studies were taken.
Step 4. Consider the exposure(s)
Case studies on immunisation
Yes, impact on immunisation reports.
Step 5. Consider the methods of analysis
Maternity Immunisation Allowance
NO

Step 6. Consider the potential sources of bias (systematic errors)
Limited to Australia
No measurement bias
Step 7. Consider the interpretation of results
What were the major findings of this paper? Describe why you think these findings were of
significance, considering the strength of association, the precision of the estimate, and whether or not
the results could be due to chance alone.
Step 8. Consider how the results of the study can be used in practice
Assessment of the impact of this policy on immunisation status using a nationally representative
population-based case-control study of 589 fully immunised controls and 190 incompletely immunised
cases, aged 28-31 months. Immunisation status was significantly associated with parent awareness of
the MIA (adjusted odds ratio (aOR) = 3.34, 95% CI = 2.28 - 4.91) and CCB (aOR = 2.08, 95% CI =
1.30 - 3.34). Only 31% of the 219 control parents who were receiving the CCB reported that they could
continue to afford child care without the assistance of the CCB.
Using qualitative tools.
The use of legislated financial immunisation incentives for parents appears to be widely accepted
among Australian parents and to have had an impact on immunisation uptake. The policy may serve
as a model for other comparable countries.
APA citation
Oldin, C., Golsäter, M., Schollin Ask, L., Fredriksson, S., & Stenmarker, M. (2019). Introduction of rotavirus
vaccination in a Swedish region: assessing parental decision‐making, obtained vaccination coverage and
resulting hospital admissions. Acta Paediatrica, 108(7). 1329-1337.
Step 1. Consider the research hypothesis
Introduction of rotavirus vaccination in Sweden

Step 2. Consider the study design
descriptive, cross-sectional study
Limitation of survey in Jönköping County, Sweden only.
Step 3. Consider the outcome variable
In quantitative and qualitative manner.
study-specific questionnaire (n = 356) and regional statistical data on vaccination coverage and
hospital admissions in Jönköping County, Sweden.
Step 4. Consider the exposure(s)
parental factors that influenced the decision to vaccinate
Yes. Questionnaire method was used to collect data.
Step 5. Consider the methods of analysis
Vaccination coverage
yes
Step 6. Consider the potential sources of bias (systematic errors)
Limited to Jonkoping County
No measurement biasness
Step 7. Consider the interpretation of results
One in five parents expressed uncertainty about whether they had sufficient information to make a
decision. However, the rotavirus vaccination coverage was elevated from 76.1% to 81.0% and the
hospital admissions due to acute gastroenteritis decreased by approximately 60%
Step 8. Consider how the results of the study can be used in practice

The results highlight the necessity for Child Health Services to have solid knowledge regarding
vaccinations, to understand individual parental issues and to support uncertain parents. No conflict.
Central aspects when deciding on vaccination were vaccine efficacy and safety, that the vaccine was
offered to all children, and recommended by healthcare professionals.
The high vaccination coverage achieved is an indication of the trust in healthcare professionals and is
considered to be a major contributing factor to the substantial reduction of hospital admissions due to
acute gastroenteritis
APA citation
Glanz, J. M., Wagner, N. M., Narwaney, K. J., Shoup, J. A., McClure, D. L., McCormick, E. V., & Daley, M.
F. (2013). A mixed methods study of parental vaccine decision making and parent–provider trust. Academic
pediatrics, 13(5). 481-488.
Step 1. Consider the research hypothesis
A mixed methods study of parental vaccine decision making and parent-provider trust.
Step 2. Consider the study design
Experimental
Mixed study methods
Step 3. Consider the outcome variable
The quantitative analysis is giving exact figures.
The fixed number of parents were studied i.e. 854 givign exact and relevant results.
Step 4. Consider the exposure(s)
One exposure group i.e. vaccine hesitant parents, accepting parents and denying parents.
Method was accurate and stratified sampling technique was used
Step 5. Consider the methods of analysis

Pilot testing was done and then mailed to 854 parents.
Yes
Step 6. Consider the potential sources of bias (systematic errors)
Study done on parents of Kaiser Permanete Colorado health plan members only.
No measurement bias is there.
Step 7. Consider the interpretation of results
The survey response rate was 52% (n = 443). Parents who refused or delayed vaccines were 2 times
more likely to report that they began thinking about vaccines before their child was born and 8 times
more likely to report that they constantly reevaluate their vaccine decisions than parents who accepted
all vaccines.
Step 8. Consider how the results of the study can be used in practice
NO conflicts.
Quantifiable data results
Such interventions identified in current research may be more effective if they are applied early
(during pregnancy) and often (pregnancy through infancy), and cover both the risks and benefits of
vaccination.
CRITICAL ANALYSIS
Theme 1: Attitude of parents towards child vaccination.
The authors, Bianco, Mascaro, Zucco & Pavia (2019), have stated in their research paper
that parents tend to delay their child’s vaccination or refuse it altogether because of a variety of
variable that impacts their decision making. The authors stated that PACV i.e. Parent Attitude
about Childhood Vaccines, a survey was an effective tool in screening the Vaccine Hesitancy i.e.
VH and determined that 24.6% parents refused to get their child vaccinated at least once.
Authors stated that communication and media along with the attitude of healthcare providers

could act as a major contributor in improving their child vaccination rates. However, this
analysis was somehow not complete i.e. it did not take into consideration all the factors that
could impact the decisions making of parents. Simply communicating the pros and cons of
getting their child vaccinated is not sufficient enough and they need to be convinced regarding
the same which will change their mind set and motivate them.
Authors, Makarić, Kolarić, Tomljenović, & Posavec (2018), have further carried research
in this field regarding the beliefs that parents of children upto 6 years of age have regarding
vaccination of their child. The authors stated that despite giving free vaccination medication to
the children and making it mandatory, the parents held a negative belief that these vaccines
would harm their child and impact their health negatively. They found that the demographic
factors were not impacting the positive or negative attitude that parents formulated towards
vaccination and rather the education level was the major factor. They identified rather than
simply communicating the benefits of child vaccination, as previous author, Bianco and et.al.
(2019), had also stated, it is necessary to educate them and foster a better and more informed as
well as advanced knowledge regarding vaccination and to evaluate their perceptions regarding
the constraints and safety issues so that they can be modified and addressed accordingly. The
authors collected overall 542 questionnaires that were filled by various parents and these were
then evaluated by implementing various statistical tools and it was found that out of the total
respondents, although majority of the parents i.e. 61.8% reported that vaccination is necessary,
yet there was a significant 38.2% who found vaccination to have a negative effect and did not
intend to get their child vaccinated despite it being mandatory for their child.
However this research paper review was also not sufficient since it didn’t incorporate the
factor that many families had family doctors and practitioners i.e. they did not have any
sufficient knowledge regarding he various treatments and depended on their family practitioners.
Therefore, they could be a great medium in increasing the ratio of child vaccination rates and
levels since they can educate the families and parents in particular regarding its importance and
this can assist them in the education of the parents. Further, there are huge gaps amongst the
knowledge that parent have regarding child vaccination and the reality and this can be bridged
thus acting as a medium for further reducing the negative attitude.
Further, the parents can be educated by giving them real life examples and case studies of
children who were not vaccinated properly in their childhood and how they contaminated severe

diseases so that parents can understand that why it is important to get their child vaccinated. This
can further assist in getting timely treatment and vaccination.
Theme 2: Barriers to childhood vaccination.
Apart from the mentality of parents being a major barrier behind the decreasing or
stagnant rate of child vaccination, there are a variety of barriers that can arise otherwise as well.
Many research papers have been published on the barriers that occur and author, Jeong, Park,
Kim, Han, Go, Choi & Park (2011), has researched some of them by formulating broad
categories for specially studying the disease of measles vaccination in child. The three major
factors that are identified were lack of awareness regarding the necessity and importance of
vaccination, not taking into concern the aspect of child ebbing ill at the time of vaccination and
lastly, the vaccination not being over. These were found to be major barriers and it was also
found that the child of working parents or of those who were not much concerned about the
safety and health of their child are at an increased rate of getting contaminated or infected with
such deadly diseases due to lack of any timely vaccination being provided to them. The author
illustrated each of the barriers by highlighting some major factors under each of the three
categories of barrier such as no consideration of the fixed time interval between consequent
dosages of vaccination, working mothers being unconcerned about the importance and necessity
of giving vaccination to the child regularly etc.
However there are certain factors or additional barriers that might occur while providing
vaccination to the children and these were not illustrated in the article researched and presented
by the authors. Amongst these one major issue was lack of any access to the healthcare services
for child. There is not adequate and equitable distribution of GPs amongst fixed locations and
this can act as a barrier in getting the child vaccinated. Further, social factors were also not
included by the author like a lone parent or friends and family with negative attitude towards
getting the child vaccinated, environmental stressors etc. Apart from this, another major
contributor in child not getting vaccinated is incomplete immunisation i.e. the child was being
given the vaccinations and treatments by tut stopped in the middle way i.e. the number of pre-
determined doses that were to be given to the child were skipped or stopped leading to
incomplete immunisation. Psychological barriers is another major barrier which the authors
refused to take into account and this involved the mentality to not adopt any formal childcare
treatment plan and rather opt for traditional methods and depend on them.

Another author, Lawrence, MacIntyre, Hull & McIntyre (2004), stated that another sector
of barriers that parents face in getting the child vaccinated are the financial barriers. The authors’
researched the link that exists between the expenditure made on maternity payments and the
expenses for getting the child vaccinated. They researcher 219 parents in Australia and
concluded that there were only 31% of them who could afford to get their child vaccinated
without taking any assistance from Child Care Benefit i.e. CCB. The remaining percentage of
parents i.e. 69% had to take assistance and the parents in Australia used widely the legislated
financial immunisation incentives that had been formulated for the general public. Therefore, it
was found that there was an extreme need for financial assistance amongst the parents and this
model could act as a guide for many other countries. This is the reason behind many parents
either not choosing to go for the child vaccination programme or skipping it in the middle due to
overburdened vaccination expenditure on the limited finances available with the parents and thus
acts as another barrier towards a child getting properly immunised or vaccinated.
Theme 3: Strategies for vaccination.
There has been a variety of research on the strategist that can be adopted and
implemented on the parents who are hesitant towards getting their child vaccinated and
identification has been made of those strategies that could be implemented on the parents
effectively and could actually assist in converting them. Authors, Glanz, Wagner, Narwaney,
Shoup, McClure, McCormick & Daley (2013), conducted one such research and in this paper,
the researcher formulated seven focus groups of parents who were having children under the age
group of four years. There were a variety of conclusions that the researchers drew on the basis of
their research concluding that those parents who refused to take vaccination programmes for
their child were the ones who thought too much about the vaccination treatments and planned
extensively before the child was even born. On the other hand parents who signed up for all kind
of vaccination programmes were those who did not give much thought and consideration
believing that it is necessary to get their child vaccinated and immunised for all kinds of diseases
that they might contract in future as well. The strategies that the researcher presented for
converting parents on the positive side of getting treatment, involved getting adequate
information from their doctors and GPs regarding the importance of getting their child
vaccinated. The educational interventions were additional recommendations that the researchers

made stating that these should be taught to the parents during the time the mother is pregnant or
more preferable before it so that they could be educated the necessity of immunisation.
However apart from these, there are certain strategies the authors missed to account for
and which can be used for convincing the parents to get their child immunised. The entire
process of getting the child immunized can be electrified by integrating it with technology so that
parents can get regular update regarding the due date of getting their child vaccinated. This will
at least reduce the rate of skipping immunisation due to forgetfulness on the behalf of parents.
Further, another strategy that could work was the easier access to the healthcare services so that
parents can take advantage of the healthcare services for their child and thus increase the
percentage of child being vaccinated. Another effective strategy that can help in converting the
hesitant parents in getting their child vaccinated is conducting of regular programs in the schools
where parents or local communities surrounding the school are invited and given education or
made aware of the importance as well as necessity of getting their child vaccinated. This would
also add in the percentage of parents getting their child vaccinated.
Another authors, Oldin, Golsäter, Schollin Ask, Fredriksson & Stenmarker (2019), have
stated that in Sweden, the strategy of introducing rotavirus vaccination has helped in reducing
the number of parents resigning in getting their child vaccinated. The study highlighted that
Child Health Services were experienced to have an extremely profound knowledge and base
regarding the various child vaccinations and the issues that might arise. This study emphasised
that parents and even family practiotners who are not attached to the mainland and are not
familiar with the latest developments can lack the information regarding the latest developments
on vaccination amongst children.
CONCLUSION
The critical analysis conducted of the six articles in the report above helps in concluding
that the rate of child vaccination is as extremely lower levels and there are a large proportion of
parents who are hesitant in getting their child vaccinated. By formulating various themes, the
attitude of parents towards getting their child vaccinated was analysed followed by identification
of various barriers in getting the child immunised which were identified and then critically. This
was then concluded with the strategies that could be used for converting the resilient or hesitant
parents towards the positive side and motivating their child to get them vaccinated.

REFERENCES
Books and journals
Bianco, A., Mascaro, V., Zucco, R., & Pavia, M. (2019). Parent perspectives on childhood
vaccination: How to deal with vaccine hesitancy and refusal?. Vaccine, 37(7). 984-990.
Glanz, J. M., Wagner, N. M., Narwaney, K. J., Shoup, J. A., McClure, D. L., McCormick, E. V.,
& Daley, M. F. (2013). A mixed methods study of parental vaccine decision making and
parent–provider trust. Academic pediatrics, 13(5). 481-488.
Jeong, Y. W., Park, B. H., Kim, K. H., Han, Y. R., Go, U. Y., Choi, W. S., ... & Park, H. (2011).
Timeliness of MMR vaccination and barriers to vaccination in preschool
children. Epidemiology & Infection, 139(2). 247-256.
Lawrence, G. L., MacIntyre, C. R., Hull, B. P., & McIntyre, P. B. (2004). Effectiveness of the
linkage of child care and maternity payments to childhood immunisation. Vaccine, 22(17-
18). 2345-2350.
Makarić, Z. L., Kolarić, B., Tomljenović, M., & Posavec, M. (2018). Attitudes and beliefs
related to childhood vaccinations among parents of 6 years old children in Zagreb,
Croatia. Vaccine, 36(49). 7530-7535.
Oldin, C., Golsäter, M., Schollin Ask, L., Fredriksson, S., & Stenmarker, M. (2019). Introduction
of rotavirus vaccination in a Swedish region: assessing parental decision‐making, obtained
vaccination coverage and resulting hospital admissions. Acta Paediatrica, 108(7). 1329-
1337.
Online
[Online]. Available through: <>
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