Parental Refusal of Childhood Vaccines

This assignment focuses on a qualitative study investigating the reasons behind parental refusal of childhood vaccinations. It analyzes data from online focus groups to understand parents' perspectives and concerns regarding vaccine acceptance. The analysis draws upon relevant literature on vaccine hesitancy, qualitative research methods, and immunization policies.

Running head: PUBLIC HEALTH
Public health
Name of the student
University name
Author’s note

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Table of Contents
Part one:.................................................................................................................................2
Rationale for the chosen topic....................................................................................................2
Part two:.................................................................................................................................4
Research recruitment..................................................................................................................4
Part three:...............................................................................................................................5
Annotated bibliography..............................................................................................................5
Part four:...................................................................................................................................14
Research study design tool.......................................................................................................14
Rationale for the research design methodology.......................................................................15
Data collection and analysis.....................................................................................................17
Conclusion............................................................................................................................17
References............................................................................................................................19

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Part one:
Rationale for the chosen topic
The current topic focuses on the public health system of United States with respect to
the immunization of children. Immunization is one of the crucial steps in ensuring long-term
health of an individual and community. The immunization is provided to an individual at
different stage of their life cycle. However, childhood immunization is crucial with respect to
developing lifelong immunity. The development of immunization programs at a faster pace in
the developed countries has to lead to a vocal anti-immunization rate. The immunization
programs have led to the complete eradication of some of the diseases such as smallpox and
polio, chicken pox among the few (Dixon et al., 2017). This has led to the emergence of a
community who has never had any firsthand experience of the disease and lack sufficient
awareness regarding the precautionary methods. Some of them grow up to be least fearing of
the diseases as they never had an encounter with them (Dunn et al., 2017). Additionally,
some of them belonging to a childbearing age often fail to provide required immunization to
their children due to the lack of knowledge.
Adequate vaccination is required in order to achieve the herd immunity threshold for
vaccine-preventable diseases. Herd immunity threshold is the percentage of vaccinated
individuals within a population (Seither et al., 2015). As commented by Berezin & Eads
(2016), vaccinating a certain portion of the population can prevent the disease from
spreading. This particular threshold level varies from disease to disease and even a small drop
in the vaccination rates of the community can lead to an outbreak of the disease. Some of the
factsheets with respect to immunization in US could be reflected upon here for understanding
the gap in establishing 100% immunity at the community level. 84.6 % immunization rates
have been received for the DPT vaccines, 93.75 have been received for poliomyelitis, 91.9 %

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rates have been received for MMR, whereas only 82.7 % rates have been received for Hib
(Harmsen et al., 2018). In order to understand the gap, we need to understand the psychology
first. There are a huge number of doubts in the minds of the parents of children of
immunization age. As mentioned by Rabinowitz, Latella, Stern & Jost (2016), the general
physician is the one and only resort the parents have with respect to gathering sufficient
information regarding the immunization programs. As argued by Martin. Lowery, Brand,
Gold & Horlick (2015), the inclination of the new age parents towards the use of digital
media for gathering health-related information can often have more negative consequences
than positive. Some of the rigorously written academic journals often mention the onset of a
certain disease as the side-effect of vaccination (Favin, Steinglass, Fields, Banerjee &
Sawhney, 2018). As a healthcare practitioner one, therefore, needs to ensure that the health
and safety of the children is not only the sole criterion of the parents but also the healthcare
providers. The parents are also concerned regarding the side effects of the immunization
doses. Therefore, the healthcare provider needs to emphasize the long-term health benefits
rather than focusing on the short-term goals.
Therefore, practicing as a healthcare professional one often have to face situations
where it will be difficult for them to convince the visiting parents regarding the benefits of
vaccines. They might go one say that the disease no longer exists, therefore there is no need
for immunization. Additionally, they may emphasize that none within their family circle ever
had the disease, reducing the chances of the disease. Additionally, evaluating and
categorizing the audience helps in understanding the dilemma faced by them more
effectively. Cultural beliefs and paradoxes often govern the health behavior of the population
(Rabinowitz et al., 2016). For example, many in the developing countries are simply
apprehensive to discuss regarding the benefits of HPV vaccine owing to privacy concerns.

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Part two:
Research recruitment
The recruitment process forms a crucial component of the research. The success of a
research project is governed a lot by the recruitment process. The sample selection is one of
the determining steps of the research process (Delaney, 2015). In this respect, the sample
consists of the parents of the children undergoing immunization programs at number of
hospitals across US. In this respect, sufficient support and cooperation are needed from the
hospital administration. In the lack of initiative, such a program may fail to reach its desired
goals.
The immunization education program may be delivered to the target group of
population using a number of resources. The particular resources which will be selected over
here include audio-visual broadcast (Fefferman & Naumova, 2015). The program may be
delivered within the waiting rooms of the hospital with the help of sufficient resources. This
may be a suitable means of educating the target population along with encouraging questions
and answer sessions. The interactive session will further help in removing the biases from the
minds of the participants. The success of the program may be evaluated with the help of
conducting interviews. Therefore, qualitative methods of data collection will be used by the
researcher for analyzing the paradigm brought about within the thought process of the parents
regarding the immunization programs.
The sample is designed from amongst parents who have been often visiting the doctor
with a number of queries related to immunization benefits and side effects. Some of them
have been recommended by the consultant physician to attend the immunization education
week. However, the selection of the participants for the interview will be done on a random
basis. The simple random probability chosen will rule out the chances of biases in setting of

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an experimental design (Lewis, 2015). Additionally, the process will provide equal chances
to each and every respondent to participate in the interview process.
The respondents will be invited for participating in the interview process wilfully, that
is none of the participants will be forced by the researcher to become a part of the research
(Newington & Metcalfe, 2014). In this respect, electronic mail will be used for informing the
participants regarding the interview process.
Part three:
Annotated bibliography
Journal 1:
Berry, N. J., Henry, A., Danchin, M., Trevena, L. J., Willaby, H. W., & Leask, J. (2017).
When parents won’t vaccinate their children: a qualitative investigation of australian primary
care providers’ experiences. BMC Pediatrics, 17, 19. http://doi.org/10.1186/s12887-017-
0783-2
Summary of source
The primary aims of the study are to identify the challenges faced and the strategies
which had been implemented by the general practitioners and nurses working in
immunization centers with parents who choose not to vaccinate their children. In this respect,
primary care providers were selected from different regions through Australian Childhood
Immunization Register (ACIR). Interviews were conducted in order to analyze the challenges
healthcare providers faced in their interactions with the parents unwilling to provide their
child with immunization doses.

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Strengths and weaknesses
The source highlights the clinical dilemma faced by the healthcare providers in
convincing the parents for signing the immunization forms. However, mixed reviews have
been received from the healthcare professionals regarding signing forms with the parents of
the children, exempting them from getting their child immunized. Additionally, the approach
used by the healthcare providers in dealing with the parents gives an account of their
individual behavior. However, it provides no appropriate way to measure them. Additionally,
the source over-represents the views of the doctors and gives less weightage to the opinions
of the nurses which results in a discrepancy in results.
Relevance
The journal selected over here is relevant to the case study chosen as it helps in
understanding the clinical dilemma faced by the healthcare providers in dealing with the
parents against immunization process. The journal can help in designing the research
recruitment.
Personal conclusions
I think the qualitative design adopted for the assignment helps in unraveling the
ethical dilemma faced by the healthcare providers in convincing the parents for getting their
children immunized. However, it does little to measure their behavior, as well as the views of
the nurses, are underrepresented, whereas they are the ones who are dealing with the parents
in the first-hand basis.
Author background
The paper has been penned down by six authors affiliated to renowned research
institutes. Berry is a fellow of the Sydney school of public health, whereas Henry works in

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the R&D department of the Lismore Base hospital. Danchin had been conducting research at
Murdoch children’s research institute.
Journal 2:
Favin, M., Steinglass, R., Fields, R., Banerjee, K., & Sawhney, M. (2018). Why children are
not vaccinated: a review of the grey literature, 115-216.
Source summary
The main aim of the study was to understand the causes behind under immunization
as well as find out a strong connection between the causes and the consequences. It can be
used to support the research rationale.
Strengths and weakness of the journal
A detailed case study analysis was conducted for carrying out the research study. The
causes for the under immunization were supported by facts and data from randomized studies
conducted across poor and middle incomes countries. However, there were a number of gaps
in the literature study as it failed to acknowledge the relevant literature sources in other
languages. The reviewer’s accuracy in extracting the key factors from the documents is
another limitation.
Relevance of the source
The source helps in establishing the relationship between cause and outcomes by
taking into consideration various intrinsic factors such as cultural beliefs and low income. It
helps in representing the low rates of immunization qualitatively. However, in my opinion,
representing lack of ability to scrutinize literature sources from other countries may result in
missing out important data.

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Author background
The article has been penned down by five authors who are the research fellows from
esteemed universities. Favin has been conducting his research studies with the Manoff group.
Bannerjee is a fellow of the expanded immunization programs at the world health centres.
Journal 3:
Harmsen, I., Mollema, L., Ruiter, R., Paulussen, T., de Melker, H., & Kok, G. (2018). Why
parents refuse childhood vaccination: a qualitative study using online focus groups, 145-165.
Summary of the source
The aim of the study is to find out the plausible causes for parents refusing to give
vaccination to their children. In this respect, a qualitative study using online focus groups had
been conducted. The journal can be used to design the research recruitment.
Critiquing the journal
The study was conducted online which made answering the questions easier for the
participants as they could choose their sole time for answering the questions. Additionally,
time could be saved through accurate storing of discussion data. However, there were
loopholes in the study conducted as insufficient information was recorded regarding the
national immunization program (NIP), which could be attributed to less trust in the
conducting authority.
Relevance of the case scenario
The study provides an in-depth insight into the perception of parents who deliberately
refused to provide their child with immunizations programs.
Author background

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The paper has been compiled by six authors affiliated to different school of research.
Harmsen is a fellow of National Institute for public health and the environment, whereas
Router works at the department of work and special psychology Maastricht University.
Journal 4:
Handy LK, Maroudi S, Powell M, Nfila B, Moser C, Japa I, et al. (2017) The impact of
access to immunization information on vaccine acceptance in three countries. PLoS ONE
12(8): e0180759. https://doi.org/10.1371/journal. pone.0180759
Summary of source
The aim of the study was to evaluate knowledge and attitude regarding vaccines and
vaccine preventable diseases in caregivers and immunization providers of Botswana,
dominion republic and Greece. The goal was to find out the impact of access to information
sources on vaccine acceptance. It can be used to plan the research recruitment.
Critiquing the journal
The journal helps in understanding the impact of presentation of adequate information
regarding vaccination and the impact produced by the same upon the health behavior of the
parents. However, the study pointed to the requirement of country specific data which will
help in understanding the gap in communication regarding dissemination of adequate
information.
Relevance of the source
The source helps in understanding the importance of effective communitarian in
altering the perspective of the parents regarding the immunization programs. However, in my

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opinion, difficulty in conducting a cross-country study could lead to gaps in collection of
adequate results.
Author background
The paper has been written by handy who is a fellow at the department of pediatrics,
the Sidney kemmel medical centre at Thomas Jefferson University , whereas Maroudi is a
fellow at the collaborative center for clinical epidemiology.
Journal 5:
Gilkey MB, McRee A-L, Magnus BE, Reiter PL, Dempsey AF, Brewer NT (2016)
Vaccination Confidence and Parental Refusal/Delay of Early Childhood Vaccines. PLoS
ONE 11(7): e0159087. https://doi.org/10.1371/journal.pone.0159087
Source summary
The aim of the program was to address the hesitation found in parents regarding early
childhood vaccination. The vaccine validation confidence scale was validated using data from
large population-based sample of US parents.
Strengths and weakness of the journal
The major strength of this study is that the results are collected from large-scale
population samples. Additionally, separate logistic regression models were used to access
association between parents mean scores on an 8 item vaccination confidence scale.
Source relevance
The study conducted was highly relevant to the chosen topic as it employs an
evidence-based tool for gathering of sufficient information for the research recruitment.

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Background of the author
The main author of the paper is Gilkey who is a fellow researcher in the Department
of population medicine, Harvard medical school. The co-author of the paper is MCRee who
is a fellow in the department of pediatrics, university of Minnesota.
Journal 6:
E. Dubé, J. A. Bettinger, B. Halperin, R. Bradet, F. Lavoie, C. Sauvageau, V. Gilca, N.
Boulianne; Determinants of parents’ decision to vaccinate their children against rotavirus:
results of a longitudinal study, Health Education Research, Volume 27, Issue 6, 1 December
2012, Pages 1069–1080, https://doi.org/10.1093/her/cys088
Summary of the source
The aim of the research study was to find the determinants which affect the decision
of the parents in getting their children vaccinated. A survey was conducted in two phases to
obtain the required results and data.
Critiquing the journal
The study was accessed with the help of a survey where the participants were
provided information sheets on rotavirus disease and rotavirus vaccine. This was done to
ensure that all the participants had similar level of knowledge regarding the disease and
vaccination which further made the assessment easy.
Relevance of the source
The source was relevant as it mainly based the judgments upon the psychological or
intrinsic factors which varied with individual participants of the survey process. It can be
used to explain the rationale.

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Author background
The article had been written by utmost 8 authors who were affiliated to different
research institutes. Bettinger belonged to the department of pediatrics, university of British
Columbia. Due belong to the department of social medicine, university of Canada.
Journal 7:
Fadda, M., Depping, M. K., & Schulz, P. J. (2015). Addressing issues of vaccination literacy
and psychological empowerment in the measles-mumps-rubella (MMR) vaccination
decision-making: a qualitative study. BMC Public Health, 15, 836.
http://doi.org/10.1186/s12889-015-2200-9
Source summary
The primary aim of the qualitative study is to understand what drives the parents in
getting their child immunized. The study conducted gives special reference to vaccination
literacy and psychological empowerment.
Strength and weakness of the journal
The conducted study provides a number of implications at multiple levels. However,
it fails to pay attention to communicative styles in recommending the vaccination to the
parents.
Source relevance
An inductive thematic analysis helps in understanding the psychological attributes
behind the decision making. It can be used to design the rationale.

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Author background
The article has been cited by Fadda who belongs to the institute of communication
and health, institute of communication and sciences.
Journal 8:
Capella, V. (2018). Legal and ethical issues concerning the rejection of vaccines, and
proposals for a necessary debate. [online] Assets.comitedebioetica.es. Available at:
http://assets.comitedebioetica.es/files/documentacion/en/legal-ethical-issues-rejection-
vaccines-proposals-necessary-debate.pdf [Accessed 3 Feb. 2018].
Summary of the source
The article discusses the rejection of vaccination in details and the different paradoxes
governing it.
Critiquing the journal
The journal compares the paradoxes with respect to vaccination in different countries.
However, the highest amount of mistrust for vaccines is probably in the country which has
received the maximum success rates. However, the literature fails to address the gap
sufficiently.
Relevance of the source
The source helps in highlighting the different paradoxes and false beliefs regarding
the immunization programs within the cross-cultural society. It can be used to design the
recruitment process.

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Part four:
Research study design tool
Description of the research design tool
For the current research, a qualitative data collection method will be used by the
researcher. The researcher will use primary research for gathering specific data related to
immunization programs. The primary data collection method could be divided into
quantitative methods and qualitative methods (Creswell & Creswell, 2017). The qualitative
method consists of a questionnaire which will be presented to the parents covering different
areas of immunization benefits as well as analyzing the problem situation, which prevents
them from taking their child for vaccination programs. The responses collected will help the
researcher in finding out the paradoxes associated with immunization and help in designing
of effective education programs (Robinson, 2014).
There are a number of factors which needs to be kept in mind while designing the
interview questionnaire. The interview guide ensures that the same protocol for inquiry is
followed by each and every person. The guide serves a checklist which helps in ensuring that
the researcher meets the required criteria of the interview process (Padgett, 2016). As
commented by Corbin, Strauss & Strauss (2014), the interview guide helps in utilizing the
limited time available in the best possible way by reducing the chances of confusion. The
guide helps in keeping interactions focused at the same time allows the individual perceptions
and opinions to emerge.
However, designing a proper interview guide is crucial in achieving success in the
research process. The questions are designed based on the research objectives which gives the
research proper direction by focusing on the areas to be explored. As commented by O’Brien,

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Harris, Beckman, Reed & Cook (2014), the researcher will need to do sufficient literature
analysis for designing an effective interview guide. One of the important criterions which
will be kept in the mind of the researcher while designing the research questionnaire is that
the cultural faiths and beliefs of the participants will be respected by the researcher.
The interviews provide the researchers with sufficient understanding about the
thoughts and opinions of the participants. In this respect, the researcher will follow an
Interview Protocol Refinement framework (IPR) for enhancing the reliability of the research
questions. By improving the interview protocols the interviewer can enhance the quality of
data collected from the interview process (Castillo-Montoya, 2016). The feedback from the
respondents of the interview process helps in removing the communication gaps (Palvia,
Baqir & Nemati, 2014). It also helps in understanding the reliability of the thought process of
the participants with that of the interviewer.
Rationale for the research design methodology
The research design methodology selected by the researcher further governs the
success of the research study. In this respect, the researcher will use a primary qualitative
research design. That is semi-structured interview based questionnaire will be used by the
researcher. An open-ended questionnaire will be used by the researcher for the collection of
data. The open-ended questionnaires will help in expansion of the data rather than a simple
yes or no received from a close-ended questionnaire (Smith, 2015). The close-ended
questionnaire leads to restrictions in the data collection process. It helps in analyzing the
problem situation of the participants in more detail. The responses of the candidates will be
video recorded and made into transcripts by the interviewer. Some of these transcripts will be
reflected by the researcher later on for correlating with the research questions.

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Additionally, a positivist research philosophy will be used by the researcher. The
positivist research philosophy adopted will help the researcher in gaining factual knowledge
based on observation and data (Holloway & Galvin, 2016). A deductive approach will be
used by the researcher in developing a hypothesis based on existing theories. The deductive
approach selected will help the researcher in establishing the relationship between specific
variables.
The researcher will employ a descriptive research design over here which will help
them in evaluating the problem situation by collecting sufficient data. Thus, integrating a
descriptive research design within the research study will help the researcher in analyzing
non-quantified topics (Thorne, 2016).
However, the ethical concern also forms an important component of the research
study. In this respect, the participants of the interview process need to be informed well in
advance. That is, the healthcare centre where the immunization educational program is
organized needs to take initiatives to inform the parents of the children who are registered
with the hospices for the immunization programs.
Designing of an interview questionnaire:
In this respect, a number of questions will be framed by the researcher for gathering
and collection of data. Some of the questions have been enlisted as below:
Question 1. How do you think the immunization programs can provide your child with a
better health?
Question 2. Why do you think skipping the vaccination doses will not cause your child much
of harm?

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Question 3: How do you think the attending educational seminars on the effectivity of
immunization programs have reshaped your thoughts?
Question 4: Do you think the community healthcare is negligent with respect to
implementing active immunization programs? If so, why?
Question 5: How do you want to help with respect to completing the vaccination doses of
your child?
Data collection and analysis
In this respect, the researcher will use a semi-structured open-ended questionnaire for
the collection and gathering of data. For each question, several responses will be collected by
the researcher. The recordings of the interview will be made into transcripts which will act as
source reference for the researcher. The recordings of the interview will be used by the
researcher for analyzing the problem situation. The points mentioned by the participants will
be expanded into a future action plan. The researcher will use the objectives and the research
questions for designing of the interview questionnaire. This finding will be later correlated by
the researcher with the main aim or objectives of the research. However, as argued by
(Castillo-Montoya, 2017), there are a number of loopholes in the interview process. This is
because some of the responses collected during the interview process may be biased and lead
to misinterpretation of the results.
Conclusion
Therefore, a detailed review of the literature may help the researcher in removing the
gaps which emerge during the research process. Confidentiality is another important factor
which needs to be taken into consideration while conducting the interview process.
Additionally, the anonymity of the participants will be maintained by the researcher while

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drafting the final report. This will help in maintaining the research ethics and rights of the
participants.

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References
Berezin, M., & Eads, A. (2016). Risk is for the rich? Childhood vaccination resistance and a
culture of health. Social Science & Medicine, 165, 233-245.
Castillo-Montoya, M. (2016). Preparing for interview research: The interview protocol
refinement framework. The Qualitative Report, 21(5), 811-831.
Castillo-Montoya, M. (2017). Deepening understanding of prior knowledge: what diverse
first-generation college students in the US can teach us. Teaching in Higher
Education, 22(5), 587-603.
Corbin, J., Strauss, A., & Strauss, A. L. (2014). Basics of qualitative research. London:Sage,
111-124.
Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and
mixed methods approaches. London:Sage publications, 54-68.
Delaney, M. (2015). The Flaws of “Herd Immunity”: Whose Duty Is It to Protect the Very
Young/Old, Pregnant, Vaccine Allergic, and the Immunosuppressed?. Journal of
Emergency Nursing, 41(3), 183-184.
Dixon, B. E., Kasting, M. L., Wilson, S., Kulkarni, A., Zimet, G. D., & Downs, S. M. (2017).
Health care providers’ perceptions of use and influence of clinical decision support
reminders: qualitative study following a randomized trial to improve HPV vaccination
rates. BMC medical informatics and decision making, 17(1), 119.
Dunn, A. C., Black, C. L., Arnold, J., Brodine, S., Waalen, J., & Binkin, N. (2015).
Childhood vaccination coverage rates among military dependents in the United
States. Pediatrics, 135(5), e1148-e1156.

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Favin, M., Steinglass, R., Fields, R., Banerjee, K., & Sawhney, M. (2018). Why children are
not vaccinated: a review of the grey literature, 115-216.
Fefferman, N. H., & Naumova, E. N. (2015). Dangers of vaccine refusal near the herd
immunity threshold: a modelling study. The Lancet Infectious Diseases, 15(8), 922-
926.
Harmsen, I., Mollema, L., Ruiter, R., Paulussen, T., de Melker, H., & Kok, G. (2018). Why
parents refuse childhood vaccination: a qualitative study using online focus groups,
145-165.
Holloway, I., & Galvin, K. (2016). Qualitative research in nursing and healthcare. New
Jersey: John Wiley & Sons, 111-131.
Lewis, S. (2015). Qualitative inquiry and research design: Choosing among five
approaches. Health promotion practice, 16(4), 473-475.
Martin, D. W., Lowery, N. E., Brand, B., Gold, R., & Horlick, G. (2015). Immunization
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Metcalf, C. J. E., Andreasen, V., Bjørnstad, O. N., Eames, K., Edmunds, W. J., Funk, S., ... &
Grenfell, B. T. (2015). Seven challenges in modeling vaccine preventable
diseases. Epidemics, 10, 11-15.
Newington, L., & Metcalfe, A. (2014). Factors influencing recruitment to research:
qualitative study of the experiences and perceptions of research teams. BMC medical
research methodology, 14(1), 10.

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O’Brien, B. C., Harris, I. B., Beckman, T. J., Reed, D. A., & Cook, D. A. (2014). Standards
for reporting qualitative research: a synthesis of recommendations. Academic
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Rabinowitz, M., Latella, L., Stern, C., & Jost, J. T. (2016). Beliefs about childhood
vaccination in the United States: Political ideology, false consensus, and the illusion
of uniqueness. PloS one, 11(7), e0158382.
Robinson, O. C. (2014). Sampling in interview-based qualitative research: A theoretical and
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Seither, R., Calhoun, K., Knighton, C. L., Mellerson, J., Meador, S., Tippins, A., & Dietz, V.
(2015). Vaccination coverage among children in kindergarten—United States, 2014–
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London:Sage, 125-134.
Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (Vol.
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