ASSESSMENT 2

Assessment 2: Literature Review

PUBH6008: Capstone A: Applied Research Project in Public Health

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Abstract

Vaccine Hesitancy has become an increasingly recognised issue in Australia and all over the

world and this is because of the fact that the concerns about the vaccines as well as their

safety takes over the place than the risks associated with the vaccine preventable diseases. In

Australia, the perception of the parents who decline or accept the vaccination and their

importance has become the subject for the investigation. The experience of the health

providers as well as the clinical experts who encounter such vaccine hesitant parents has not

received much attention till date. However, childhood vaccination programs and their

benefits outweighs the risks but despite this, few parents decide to not to get their children

vaccinated. It has been observed that many of Australian children are under-vaccinated due to

the refusal by the parents as well as due to various concerns regarding the safety of the

vaccines. The safety of the vaccines scares the general public and therefore it has been

observed that it undermine the confidence of the parents in the vaccines and hence decrease

the immunisation rate in Australia. However understanding their concerns and addressing

their concerns can help in lessening the impact and increasing the vaccine rates in Australia.

The aim of the following study is to have an understanding of the perceived risks as well as

the benefits that are incurred by the vaccination that affects their decision to get their children

vaccinated or not. Moreover, the following study aims to provide the understanding of the

various challenges that are faced by the health practitioners and the strategies used by them

when encountering such vaccine hesitant parents. The main objective is to describe the

behaviour of the Australian parents, their beliefs, attitude, their concerns about the

vaccination as well as the various sources of information that are provided by the health care

professionals to the Australian parents.

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Introduction

This study aims to focus on the research question i.e. “How the Australian parents perceive

the need to immunise their children against diseases?”

It has been observed that growing number of parents in Australia and all over the world either

delay vaccinations or simply refuse to get their children vaccinated against vaccine

preventable diseases. This is turn leads to the increased risk of the outbreak of the vaccine-

preventable diseases and hence disrupting the immunity of the population which in turn leads

to the decrease in the trust of the people on the capabilities of the health care systems and the

health care providers to protect the people from such diseases [ CITATION Kaj18 \l 16393 ].

Vaccine hesitancy takes place due to many reasons and is related with various psychological

as well as demographic determinants which includes factors like parental attitude towards the

vaccines, social norms prevalent in society, religious beliefs and trust on vaccines and health

care systems. The main aim of the following study is to have the understanding of the factors

that acts as determinants of the parental perception of the need of the vaccination for their

children against the contraception of infectious diseases. The role of the parents is most

crucial in the process of getting the children immunised against diseases as they are the one

who makes the final decision regarding vaccinating or not vaccinating their child. However,

the fact that the decision regarding whether or not to vaccinate the child is highly related to

the child’s future health and therefore the vaccine related decisions holds high position for the

parents as they involve the health of their ward. However, the parents are often

overemphasised about the potential side-effects that arises in the children out of the

vaccination and therefore this becomes one of the most important factors that have a

significant influence on the decisions made by the parents and hence leads to the parents

finally refusing to get their children vaccinated. The majority of the Australian parents are

found to get their children vaccinated without having any issue or concern. However,
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according to the studies conducted it has also been found that at present, the rate of

vaccination in Australia is quite satisfactory and stable which ranges from 90-92.5% in

children who are below 7 years of age. At the same time it has also been found that almost

7% of the Australian Children are under-vaccinated or not at all vaccinated accounting to

various psychological, religious or demographic barriers. This proportion of children and

their parents does not understand the importance of the vaccination for the health of the child

and simply refuse to get vaccinated at any cost. The government of Australia as well as

according to WHO, the vaccination rate should be at least 95% or high which means that

Australia still needs to improve this percentage in order to meet the national target. Also it

has been found that most of the children who are non-immunised belong to some particular

cluster regions of Australia and therefore this vaccine hesitancy is believed to have occurred

out of societal impact. Such people residing in cluster region of Australia mainly believe that

the risks associated with the vaccines are far more than the dangers arising out of the diseases

and that they can very well handle the disease in case it develops and hence decide not to get

their children immunised as it will only weaken their immune system by unnecessary dosage

of toxic chemicals. Furthermore, the vaccine hesitant parents have their own concerns and

questions regarding the safety of the vaccines and their overdose and side-effects. In the

absence of the necessary answer to their questions and the information required, such parents

perceive vaccination as not an important aspect and hence refuse to get vaccinated. On the

contrary , few of the Australian parents are so scared that they raise their concerns on social

media platforms in order to get the assurance from other parents regarding the safety of the

vaccines. In case they encounter any negative parent, they also tend to build negative attitude

towards vaccines.
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In the following study, we will try to understand the factors that decide the perception of the

parents for getting their children immunised and reason that promote vaccine hesitancy in

Australia.

Literature Review

The beliefs of the parents greatly influence their decision to accept the vaccination and how

do they perceive the need as well as the risks associated with the vaccination remains

subjective. The hesitancy of the parents towards getting their children vaccinated and

immunised has become an issue of global concern in the world. The vaccine hesitancy among

the parents can be referred to as the degree of the parental concerns regarding the various

vaccines and hence the immunisation. It has been observed that few parents are complete

immunisers while few are incomplete immunisers. The complete immunisers tend to be

fearful of the outcomes of the various unfamiliar as well as deadly diseases and hence these

kind of parents get their children immunised. On the contrary, incomplete immunisers do not

consider vaccines to be effective against such diseases and hence avoid getting their children

immunised. Moreover, non-immunisers tend to be more fearful of the long term side effects

of the vaccines as they believe that these vaccines are the kind of social experiment which the

health providers and medical associations are performing on their children and hence they do

not consider it important to get their children vaccinated but feel that proper diet and building

up their general immunity is a much better alternative.

Childhood vaccination is extremely important as it protects the individual as well as the

community and society from various infectious diseases and hence contributes in reducing

the occurrence of large amount of mortality. These vaccinations are generally licensed as they

aim to protect the population from the severe infectious diseases that can prove to be highly

harmful for the individuals and their community. Therefore WHO recommends the uptake of
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minimum 90% or in some cases 95% vaccination in order to achieve protection from harmful

infectious diseases. In order to achieve this, the government of the Australia as well as all

over the world have created strict systems that makes sure that vaccines are properly

scheduled and the disease pattern changes over time and also to ensure that all the vaccines

are affordable as well as easily accessible by the common people.

It has been observed that in Australia, most of the children receive all the essential

vaccinations as per the recommended schedule. As per the data observed in the year 2018,

approximately 94.04% of children were found to be fully vaccinated within the age group of

1-12 months. In addition to this, approximately 94.6% of the children were found to be

vaccinated in the age group of 1-5 years of age. However at the same time it was observed

that there exists a category of parents that have their own reasons for the objection for

vaccines and these reasons are either related to their religious beliefs or their personal

thinking. In the year 2016, approximately 1.77% of the parents were found to have views

against vaccination and hence they did not consider it important to get their children

immunised on time. The refusal for the vaccine has potentially various negative health

consequences for the child as well as for the whole community especially in the communities

where the number of such vaccine refusals are more. It has been observed that most of the

parents that have objection in immunising their children belonged to some particular

community and hence live under a defined geographical region where the risks of the

infectious diseases becomes more.

In Australia, health professionals including general practitioners, paediatricians, maternal and

child health practitioners etc. frequently come across parents and families who choose not to

vaccinate their children. In fact most of the time these health practitioner’s encounters with

such parents and their families are really challenging. Due to the various reasons such as time

limits, system issues limits such health professionals to address the individual concern of
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every single parent and provide them necessary and sufficient information in relation with the

importance of vaccines for their children. However, in some of the Australian states, the

vaccination refusal has been incurred with the severe financial penalties as per the Australian

legislation. Many of the parents among the non-immunisers wants to justify their viewpoint

and hence they exert pressure on the health professionals to either provide them the reason or

justify their viewpoint. This is due to the absence of the no-fault vaccination injury

compensation scheme by the government of Australia. However, there are very few cases

where there occurs a long term adverse effect of some vaccine on a children or an individual

but in such cases, the parents need to face the sole responsibility for their ward as there is no

compensation scheme from the Australian Government. However, there are such schemes

available in more than 19 countries across the world where the government provides adequate

support to the family of the affected child or children.

The perspectives of the non-immunisers and the non-vaccinating parents creates several

roadblocks for the various health professionals where the communication between the health

provider and the parent does not come to any conclusion and remains as a standstill. The

health professionals in Australia face serious struggles while encountering such non-

vaccinating parents who have a non-medical history of disease and hence they

straightforwardly decline the opportunity to get their children vaccinated and hence

contribute to the well-being of the better and disease free community.

Such encounters between the medical and health practitioners and the non-vaccinating parent

places both of them in the challenging situation where their ability to understand, make

another one understand as well as their beliefs are challenged. As observed, in order to get

positive and improved response from such parents, the health professionals needs to adopt

non-judgemental and an empathic approach so as to deal with such non-immunisers. It has

been found over years that almost all the parents who are going to get their children
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immunised through vaccinations seek to obtain information about the vaccine and therefore

asks questions from the vaccine provider or the health professional.

Also it has been found that most of the parents who are against vaccinations or who decline

getting their children vaccinated do so in the climate of societal pressure which has been

portrayed to them from the non-vaccinating parents. The government of Australia as well as

the Australian media have often labelled such parents as irresponsible rogues as well as baby

killers and the enemy of the healthy community.

On the basis of the several studies that have been conducted, various characteristics of

hesitant as well as non-vaccinating parents have been identified. These studies have also

identified the strategies that most of the non-vaccinating parents adopt and the various

communication strategies that are used by such parents in order to influence the decision of

other parents as well. Therefore, it is important for the clinicians as well as Australian Health

providers need to be prepared to encounter such non-vaccinating parents and understand their

perspective in order to maintain effective engagement.

In Australia, except for the few highly educated mothers who make a decision to not to get

their children immunised, most of the parents do not make such decisions and their decisions

are based on the knowledge as well as the scientific evidence. Decision making among the

parents related to the importance as well as the necessity of vaccines is complex in Australia.

It has been observed that in Sydney and in many cities of Australia, the reaction of the

parents related to the distress in their children immediately after the vaccine are much

stronger than their belief and feelings on the various benefits arising from getting their

children vaccinated. It is therefore proposed that Australian government needs to encounter

such feelings through strong commitments for vaccinations, providing social support to the

parents and identification of the children that are currently suffering from such diseases.
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However, in Australia and in almost whole of the world childhood vaccination is being seen

as the cultural truism which is automatically accepted by many of the parents without much

thinking.

The main reason why many of the non-vaccinating parents believe that the risk of the disease

is low as compared to the risks associated with the side-effects of the vaccine and

ineffectiveness of the vaccination is the societal pressure. Many parents in Australia fear of

overloading their child’s immune system and therefore such parents are concerned about the

effectiveness of the vaccine, the mix of the vaccines as well as the number of vaccines

required by a child. Such fear are more prevalent among parents who have vulnerable

children such as children with asthmatic or heart problem. Most of the parents in Australia

develop the perception that vaccinations might prove dangerous for their children and hence

they believe that it is not important to immunise their children and in case disease develops in

a child, they would rather control it. Such parents doubts on the effectiveness of the vaccines

and believe that doctors and health providers overstate the benefits of the vaccine and the

dangers of the diseases. All these beliefs together make parents either delay the vaccination

or totally avoid it.

According to the most recent estimate it has been found that approximately 3.3% of the

population of children are affected in Australia due to the vaccine refusal. However, these

represents only the estimate of the vaccine-hesitant parents while many of the parents on the

contrary choose to vaccinate their children as per the National Immunisation Program

Schedule that is developed by the Australian government. These also includes those parents

who have milder hesitancy towards the vaccine and excludes the extreme cases of highly

resistant and hesitant parents. Till now, the success of the various vaccination programs in

Australia shows that Australia has been successful in controlling the occurrence of the many

vaccine-preventable diseases in the last few years. However, if more vaccine hesitant parents
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do not comply with the vaccination schedules, the outbreaks of such diseases can take place

which might threaten the immunity of the majority of the population.

In Australia, at present the government highly recommend getting all children vaccinated

through childhood vaccines on time. But despite serious efforts made by the Australian

government as well as the health practitioners, various vaccine programs fail due to the rise in

the vaccine safety scares among the local people. It has been observed that majority of the

Australian parents who do not immunise their children are concerned of its safety as well as

the risks associated with it and its side effects. This perception became highly visible after the

suspension of the CSL Fluvax due to the higher rate of febrile convulsions found in children.

In Australia at present, the vaccine coverage is high against only 1.61% of recorded vaccine

refusers. However, there is an ever increasing concern that if the health providers does not

adequately addresses the concerns and issues of the parents, the trust of the parents on the

vaccine and its effectiveness can get affected. The parental reluctance to have their children

non-immunised have led to the outbreaks of serious vaccine preventable diseases all over the

world especially in the outbreak of diseases like measles. There are evidences to show that

there have been outbreaks of this measles disease in Australia during the year 2011-12.

However, the current immunisation rate in Australia is stable and fall above 92% but it is still

under 95% that is recommended by WHO as well as the national Australian government. The

vaccine hesitancy and the belief of non-immunisers parents is the major contributing factor in

this. The refusal rates in certain states of Australia is very high. For instance, the rate is upto

7% in Australian towns like Lismore. According to the survey conducted by NHPA i.e.

National Health Priority Area during the year 2011-12, approximately 80,000 of Australian

children under the age group of 7 years were found to under immunised or non-immunised.

The reason behind this is the parental concerns regarding the safety and its serious adverse

effects upon the children. Other than this, few parents also fear of Autism and every 1 out 4
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parent has a belief that over immunisation can weaken the child immune system. Also the

Australian parents were found to have concerned about the toxic substances present in the

vaccination that could adversely affect their child’s health and immunity system. Moreover,

the consent of the children also becomes a major factor. In some of the children, consent can

be difficult as even if parents give their consent of the vaccination, the children above 5years

of age are not willing to get vaccinated. It is important that the government takes initiatives

and the health providers listen empathically with the parents and address their concerns in a

polite manner. The health providers need to respect the wishes of the parents and the children

and hence not force the decision of vaccination on the parents against their wish if they do

not think that getting vaccinated is in the interest of their child’s future health. This is because

most of the parents in Australia rely on their personal health provider or medical expert to

influence their decision and therefore looks for their guidance or support. It has been

observed that Australian mothers express their trust in their health providers and influenced

by their guidance and advice, get their children immunised.

Most of the Melbourne parents in Australia look for reliable information from the health

providers and the lack of the detailed information proves to be greatest barrier in their

decision making. However, it has been found that financial incentives can help encourage

more parental visits for children scheduled vaccinations as it has been done in France and

Britain. In Australia, GPII i.e. general Practitioner Immunisation Incentive aims at improving

the low vaccination rates by providing monetary rewards to general health practitioners as

well as financial incentives to parents.

Also, there is a need for new approaches in order to improve the vaccine confidence and the

trust of the parents on the effectiveness of the vaccines. The various approaches till now have

been focusing on the provision of the necessary and detailed information to the parents but

till now no approach has focused on the importance of the communication strategies.
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Communication helps in building trust as well as rapport and hence helps in persuading

parents when most of the other approaches fail to do so. Healthcare providers and medical

practitioners play an important role and are therefore considered as the most trusted source of

obtaining important information regarding vaccines. However, health providers themselves

require information first in order to successfully and effectively address the concerns of the

parents. Therefore there is a need to develop effective communication strategies in order to

support the parental vaccine related decision making. Usually, there are three types of parents

that are encountered by most of the health providers. The first are the acceptors who are

ready to get their children vaccinated without having any concern or issue. Secondly, there

are parents who are vaccine hesitant which includes parents who either have concerns or who

delay getting their children vaccinated but finally get their children immunised. Third is the

group of parents who are referred to as refusers as they refuse to get their children vaccinated.

Therefore, health providers need to tailor their communication strategies based on each group

of parents and hence avoid getting engaged into long and unfruitful conversations with them.

For the vaccine hesitant group of parents it is important for the health professionals to build

trust and adopt a respectful and non-judgemental approach towards them. For the total

refusers, it is required for the health providers to make them engage in consultation brief and

provide adequate and necessary information and always keep the door open for the further

discussion in the future. The health advisors can also provide them information in the form of

graphics or videos in order to address their concerns.

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Conclusion

Acceptance of the vaccines as well as vaccine hesitancy are increasingly becoming the issue

of the global importance as well as government of Australia. As per the WHO, the research

has been doubled for finding the reason behind the perception of the vaccine among the

parents. It has been observed that the decision making of the vaccine-hesitant parents is

influenced by the various factors which includes reasons such as their attitude, behaviour,

confidence, trust on the health providers and the health system etc. These factors are complex

and hard to understand. It has been found that particularly in Australia, almost one-third of

the total population i.e. almost 1/3 of the parents have serious concerns for the vaccine safety

and they hardly rely on recommended vaccination schedules as prescribed by their medical

practitioners. This becomes the major reason for their distrust and hence they become

reluctant to not to get their children vaccinated. The main reasons why few children remain

under-vaccinated or non-immunised in Australia are related to the immunisation services and

the attitude of the parents as well the information provided to them by the health providers.

Among many the most prevalent factors behind the vaccine hesitancy are inability to access

the services, the attitude of the health practitioners, trust on the health services, false

contradictions, knowledge of the vaccination, the fear among the parents of the side effects of

the vaccination, costs associated with vaccines, contradictory priorities of parents as well as

their beliefs and attitude. Therefore there is a need to develop effective communication

strategies in order to support the parental vaccine related decision making