REVl W OF TH EVID
E URRO U DI G I TERV
VA
1 E HE !TAN Y 1 PRIM RY ARE

by

lui tin
R.

PR

arter Hu el

ip l rna) , ethbridge
li ege, 200
., thaba a ni v r ity, 20 I 0

1 P RT I L ~
FILM ~ T
R THE DE R ~ F

PRA T IT J

R

UNIVER SITY OF N ORTHERN BRITISH C OL UMBIA

March 2015

© Chri ti ne Hue!, 20 15

TIO

I• OR

ll

B T RA T

In th pa t fi e y ar , th rat

f tw ha ranged b tw

immuniz d by th ag

lumbi a who hav be n fully

riti h

n 5% to 7 1%. Thi

n ur h rd immunity and t

b I w th

di ea

f children in

JT

p ndin gly, utbr ak

ut-ring with alarming frequ n y.
con cienti u I

pp

areg1

di ea

a cinati n both pro in cia ll y and fed rally.
are th e who ar \'accine-he itant

tb

uppre

c mmunicabl

i and mea I

in th pr vine are

h are philo

phi all y or

ed t r utin infant and hildh

blam ed [! r th e re-emergence f th e

tati ti c remain far

d immuniza ti n have b n

, and ~ r th I w

erage rate of

m ng th i gr up of ca regiver .[! r children

e wh are unc rtain about va cine afety and

have yet to de ide if th e

ill imm uni ze th eir hild . vid en e how th at primary ca re

pr vider , like fa mil y nur

pra titi ner , c ntinue to b c n idered a a key ource f

immuniza ti on inform ati on for th e e phil

ophi ca ll y pp

d caregiver , regardl e

f

wh th er or not th ey proc ed to acc in ate th eir children. The g al f thi project i to
pre ent th e re ult of an integrati ve lit rature rev iew th at addre e th qu e ti n " Wh at
interventi on can prim ary care nur e practiti oner empl oy in communi ca tin g
immunization afety to increa e vaccine uptake in he itant careg ivers?" A Medlin e
literature search produced 10 re earch arti cle for analys is. The Fuzzy-Trace Theory was
employed to provide the th eoretical framework for thi paper and to info rm th e rati onale
applied to th e findings identified by the review literature. Major findin g emph a ize th e
necess ity for research that evaluates intervention aimed at increasing vacc ine uptake in
hesitant caregiver , th e importance of child-centered communication u in g natTati ve and
storytelling to exp lain vaccine ri k and benefit s, and th e need for more edu cati on with
res pect to vaccination during pregnancy.

lll

T BLE OF

0

T EN T

ii

Ab tract
Table of

ontent

lll

Li t of Tabl

v

List of Figure

vi

Acknowledgem nt
hapter 1

1

1
7
7

Introduction

ac kground
Hi t ry of Vaccine pp iti n
phi al pp
Modem Day Phil
ci - ultural hange

iti n

unent a ine H itan y trat gi
pp itio n: ultipl e et rmin ant
anadi an a cin Requ irement
Phil o phi ca l pp iti n and Primary are
Phil o ophi ca l pp 1t1 n and ur e Prac titi n r Prac ti ce
The reti a! Framew rk
uzzy-Trace Theory
C hapter 2

M ethod

tep 1:
nc ptuali za ti on and earch trategy
tep 11: Preliminary earch
tep lll: Focu ed earch
tep IV : naly i and Reportin g
C hapter 3

F indi ng

Vaccine ommuni cati on ontent
hild - entred Communi cati on
Presumpti ve versu Pa1iicipatory Commun ication
arrative-Ba ed Vaccine Communi ca tion
Vaccine ommuni cati on Timing
Prenatal Vaccin e ommunicati on
Insuffi cient Evidence on Vaccin e Interventions
Chapter 4

Discu ss ion

10
Il
14

16
17
18
23
25
25

29
29
3J
33
34

36
36
37
41

46
54
54
61

66

Social Orientation and Child-Centred Vacc ine Communicati on
66
Post-moderni m, Nan ative Medi cine, and Medi ca l
Profe ionali m
69
72
Prenatal Vaccine ommunica ti on
Chapter 5

Recomm end ation s and Conclusion

Recommendati on for Prac ti ce
Recommendati n for Edu ca tion
Recomm ndation for Re ea rch

79
79
J

2

IV

11

lui 11

8

Reference

86

Appendix A

94

Appendix B

98

App ndi

99

Appendi D

100

v

LI T OF TABL
T bl 1 Eligibility criteria for integrative literature r vi win fu sion ................................ 1
Tab le 2 Search t rmsfor the integrative revi w .......................................................................... 32
Table 3 Integrative review evid nee ................................................................................................. 94
T ble 4 Canadian Immunization Guid : National Guid lines for Immunization

Practices, Selected Guide/in s Relevant to Vaccin H sitancy ................................ 99

Vl

Ll T OF FIG R 1
Figure A Conceptual mod I consisting of three domains offactors that interact and
may I ad to vaccine hesitancy at th individual lev I............................................. 98
Figure 8 Th matic analysis of the literature review findings .............................................. 100

vii
A KN OWLED

MENT

The auth r thank r. L Ia Zimm r and ~ rin Wil n, M eN P- , D r th 1r
nthu ia m, upp rt, and gu id ance in the ur e f ntributin g t thi proj e t.
I would lik t e t nd a p ial thank t m
family nur e
pra titi an r Ia mate who e mile ph n call , and nc urag ment have mad thi
JOUrn y u h a w nderful

M t all , 1 would lik t thank m fam ily wh ha had t bar my di vi led
att nti on er th pa t ·~ ur y ar . 1n thi tim , liv ha e begun and nd d, pl ac have
changed, but y ur 1 e and upp rt ha ne er wa red . r thi 1 am truly fortunate.

1
HAPTER 1

Introdu cti on
lmmunizati n pr gram ar
h alth initiati

put~ rward b

c t-effl cti e mea ur t pre

m dern 111 di cin e. The

n utbrea k

wh

pp

careg1 r

con ci nti u opp

111

t u

ful publi

pr gram prov id a afi ,

nt di ea e and prematur d ath (Public H alth

anada, 201 a) . Yet, in r
initiati e have

n id red to be on of th

e t rn c untri

g n y f

with tr ng pu bli hea lth

f accine- preventable di ea e 111 p diatri c p pul ati n

e immunizati n ('

accm

afi ty," 200 ). Phil

phi al or

iti n t routine infa nt and hildho d immunizati on in clude th

indi idual wh b lie

( r u pect)

me r all f the fo il w111g pr po itio n : that

a cme are 111 ffi cti

and harm ful to th Jmmun

y t 111 ; that adver e effect fr m

vaccme ar under-r p tied; that acci ne- pre entab le di ea

are n t hannful ; th at

upporter of vaccinati on are mo tivated by profi t and th erefore wi II v ri o k the dangers
of vaccination· and that co mpu l ry hi ldh od vaccine chedul es are a vi latio n of civil
liberti e (Fredri ck on et a!. , 2004 · Lyren & Leonard , 2006;

ield , 2008).

The degree to whic h the e propo itio n influence caregiv rs who sub cri be to
orne or all of the e beliefs will how up in th e popul ation in three broad group .
Caregiver who are philo ophi ca ll y oppo ed to immuniza ti on can be grouped on the
bas is of vaccine rej ecting individual who oppose all routine childhood vaccin es, vaccine
resistant individual who selectively chao e certain vaccines fo r th eir children, and/or

request alternative timing schedules for vaccine admini trati on, and indi vidual who are
vaccine-hesitant, as yet uncetiain about vaccine and undec ided a to whether their child

will be immunized (Hagood & Herlihy, 201 3; Publi c Health Age ncy of Canada, 201 3a) .
s enti ally, caregiver who are philosophi call y oppo ed to vaccinati on are thought to
have weighed the perceived benefit and ri sks of vaccinating their children and to have

2

hild

n to ab tain ba

d

mad a

d n their b li ef that th ey ar pr tec ting th 1r

h alth.
Th e tent t whi c h areg1 r who ar philo

will have a n gativ impact n th e rat
k for

phically ppo

mmw1ica bl di ea

( dam

n, 201 ), th e

11 % h 1i

F re port I

utbreak - i a ignificant c ncem ~ r

kin g at hild we ll -bein g in wea lthy countri es

f th e wo rld w ide av rage f 9 % fo rd

over th e pa t 10 y ar

orga li , H n , & B ute l , 201 ).

ana d ian a erag [! r full vac inati on at tw y ar

n te that full a cinati on rate fo r
and it p

f age i 84%

el p d c untri e . T he re p01i a]

anad ian hil dr n at tw yea r of age have d clined

tul ate that rum our and mi in:D rm a ti n w ith re p ct to

the afety of va c ine c uld furth er affec t vaccine uptake . Thi i
pan- anadi an urvey w hi ch n te that 50% of parent
vaccine are not a

accination

f immuniza tion[! r an entire p pulati n- by

met,
cc rding to a r c nt

dt

upp rted by a 2011

u rveyed were co ncerned th at new

afe as older acci ne , and th at 33 % of th e parent

urveyed fe lt that

children currently rece ive too m any vaccinati ons ( ko Re earch A

ciate In c ., 20 11 ).

ln Briti h Columbia the rate of vacc in ati on is even lower th an th e nati onal average,
propos in g a bleak outl ook for future di ea e co ntrol. Fo ll owi ng a study th at took p lace
between 2006 and 2007, the BC Immuni za ti on ub co mmittee reported that onl y 69% of
two-year-o ld children were full y covered- a rate that was deemed to be in adequate
(Briti sh Columbia Centre for Di sease Control (B C D ), 2009) . The Sub committee e t a
target increase of 5% per year with a view to achieving a long- tem1 coverage rate of 95 %
(whi ch wa thou ght could be achi eved by 20 15).
A vaccine coverage rate of 90% is considered optimal for m ainta inin g herd
i1mnunity on th e ba i of a red uction in th c ircul ation of patho gens within a large ly
vaccinated popu lation, and the con equent uppre sion of communi cabl di ea e

utbr ak ( in , ame ,

out that there ar pr ently h alth
ac m c
(B

rage rat

£ 11 w -up rep rt (

Heyma1m 201 1) .

a 1wa

r ic d li v ry ar a within

7%. The m

111

progre

r p rt

f J% fr m th e earlier

w hi h initiall y pr mpted th

ub

mmi ttee t

e t target ~ r increa in g

ar- ld childr n .

T h na ti nwid d c line in infa nt and chil dh
ignifi ant impa t on he rd im mun ity ra te .
communi abl di

olumbia with

-wid are up to da te on their

accinati n by the tim the reac h the age oft

accin uptake in two-

riti h

t re ent Jmmuniz B

20 14) tate that nly 6 % f hildren pr

r p rt cit d abo

, 20 14) p int d

a e, pre io u l a ra r

int rval . ln 20 l 0 and 20 14 , utbreak

utbreak

f vacci ne-prev ntab le

ccurren e, ar n w ccurring at regul ar
f mea 1

hea lth lead r to conta in th e pr ad of mea I
unimmuni zed po pulati on (

d immu nizati n uptake ha had a

in

ri ti h

olu mb ia c ha ll e nged pu bli c

and to adv ca te mea le vacc in a ti n to

, 20 13· M ak i &

arton, 20 14) . imil arly , pe rtu

outbreak in th prov ince in 20 12 and 20 13 ha e igna led a retu m of epidem ic ra te
remini cent of the la te 1990 and early 2000 (B
the lo

D , 20 13 ). Ace rdi ng to th e med ia,

of publi c confid ence in immuni za ti on is to bl am e for the recent outbreak (Pearce,

201 3; W oodward , 201 4) . T he e recent event hi ghli ght the chall enge of increa in g
vaccinati on ra te in children in order to thwaJi the furth e r pread of vacci ne-p reventab le
disea e . ln th e event that immunizati on rate co ntinue to decline- and incidence of
disea e outbreak increa e - the ri sk of ho pitali zation a nd dea th w ill needl e ly per i t
for society ' s m ost vulnerable groups, infant and the elderl y (Kennedy, Pruitt, mith , &
Garrell , 2011 ).
To reiterate, phi losophical oppos ition to vaccin ati on poses a signifi cant cha ll en ge
to hea lth ca re profess ionals as vacc ine- preve ntable co mmuni cabl e di ea e , n ot widely
experi enced for decad e , re-em erge in unvacc inated po pulation (Public Hea lth A gency

4
f anada 2006).

urn r u re ear h tudi

indicat that primary car pr

id r (P P ),

in particular pla an tmp rtant r I in th d ci i n that ar gi er ar likely t make
(M Murra et al. 2004·

m r

f thi re earch ft u

nth r

t nt to whi h th r P P
dec i ion-making pr
phil

f famil ph

uch a nw-

ician a P P , it d e n t addre

phically op p ed t imm uni za ti on , r gard l

pnmary

en wh re parent are
of whether r n t th y d cline

till identify th eir family practiti ner or P P as th Jr

urce ft r inform ati n ab ut ac me ( mer, almon,

Hal ey, 2009; alm on et al., 2005).
the pr1mary car pro ider i b th kn
immuniza ti n appear to in

th

1 ractiti ner or midwi e , influ nee thi

gen rail find that,

tudi

ac inati n for th ir childr n, th

Harri ,

Hal y, 200 ). While much

alm n,

tudie ha e al

r n tein, deHa11, &

indicated th at the extent t which

ledg ab le and c m[t riab le with the topic of
in vacci ne-h itant caregiv r (Petou 1 -

dyear- mith, Tum er, &

oe, 2004 ). hi finding indicat

that P P must be

w 11- er ed in way of appr ac hin g thi top ic give n the ]eve] of in flu nee th ey exert n
the deci ion-making proce e

f caregiver and parent .

Current recommendation for hea lth care provider worki ng with philo ophi ca ll y
oppo ed families place grea t empha i on provider/patient relationship and mpha ize
that healthcare providers are in a good position to put forward evid ence-based,
counter-argument to anti-vaccine claims (Hea ly & Pi ckering, 20 11 ; Levi, 2007 ; mith,
Kennedy, Wooten, Gust & Pickering, 2006) . Research finding (and opinion piece )
published in academic journals highlight the impmian ce of e tab li bing tru t and mutual
respect between the healthcare practitioner and their patients, arguing that thi i a key
factor in the likelihood of increa ing vaccine uptake in philoso phicall y opposed
careg ivers. However, it seems that these recommendation tend to focus on ab tract
relational qualities that wi ll vary among healthcare providers and their patients:

5
perc pti n

f th

hara teri tic of a tru tful r lation hip b tw en practitioner and

patient can dif£ r b twe n pra titi ner and b tw en patient (H aly & Pickering 20 11 ;
VI

2007).
omm ndati n ~ r way in which t

Th re ear h lit ratur al

pro ide r

va

ing th at anti-vaccin argum nt can be counter d with

addr

in h

ev idenc -ba
cow· e of

itancy, prop

d information pr

ided by way fan

p n

mmunication tyle in the

un ellin g (Hea ly & Pi ckering , 20 11 ; e i, 20 7 ; mith e t al. , 2006 ; " Vaccine

afety' 2009) . H we er th ere i n evidenc tha t pr vi din g go d m edi ca l inform a tion
ab ut tb

afety of accine wi ll increa e patient under tandin g r improve immuni za ti n

uptak (M cM urray et al. , 2 04 ).

n the who le, re earcb finding in th e litera ture do no t

outline pecific tra teg ie or intervention tha t hea ltb car providers might emp loy to
convey th e afety ofva c in ati on t he itant caregi er ; de pite th e fact th at uch
interventi n could ffe r a cleare r directi o n n bow to increa e immunization uptake.
The purpo e of thi project i t pre e nt an int grati ve literature review to addre
the question of"Wbat interventi n can primary care nur e practiti oner emp loy in
communicating immuni za ti n afety in order to in crea e vacc in e uptake in h e itant
careg iver ?" Thi project will co ntribute to moving th e focu away from the relational
aspects of primary care by identi fyi ng th ere earch th at ha been hown to be helpful in
conveying the m essage to caregivers that vaccinating children i not only afe but is a l o
a preventive health m easure.
At th e sam e time, th e purpo e of thi s review is not to diminish or nega te th e va lue
of posi ti ve , tru st-imbued pati en t/prov ider relation hip s wh en it co m es to influenci ng
decisions about vaccination. Instead , this review propo es that, while th e ex i tence of a
trustful relationship between patient and healthcare pro vide r play an important role in
communicatin g the safety and importance of vaccine , more i needed for thi to be

f:[i cti

or influ ntial wh n it

m

t incr a in g a cm uptak . iteratur that l

k

nly at the po itiv a pect of tru tful pati nt r lati n hip a am an t impr ve
ac in -uptake I a e littl t go on D r h althcar pr vid r wh alr ady ha ve g
lini al relation hip yet till tru ggl to incr a
Th findin g
by

d

accin uptak .

f thi re iew are e amin d u ing the fu zzy- trace theory, a outlined

rainerd and R yna (200 1). Thi the r ti cal framework i empl yed b re to pr vide a

mean toe amin e why trategie G r increa ing va

ine uptake in h itant caregiver may

r may n t be u c

ful , and wh current appr a he t

ucce ful (K mp

t al. 20 I l ).

It i n t tb purpo e of thi r

iew t

~ cu

a ine he itancy have n t been

n caregi er who ve hementl y reject

va cinati on. Re arch indi ca te that thi group i th lea t like ly t be pent furth er
di cu ion, or to be influenced by edu cati onal initia ti ve given th ir irrati nal belief
y tern (Hag

d & Herlih y, 20 13 . In tead, the foc u

r thi rev i w i on ev id ence-ba ed

trategie that nur e prac titi ner and other P P workin g with careg ive r might empl oy
with tho e who are vaccine-he itant, on th e ba i that thi gro up i con idered more likely
to take into account and ac t on inform ati on put forward by hea lthcare provider (Hago d
& Herlihy, 2013 ).

Thi s paper will fir t pre ent the background to the re earch qu es ti on, fo ll owed by
an explanation of the fu zzy- trace theory, and then a de cripti on of th e method used to
select the data. This will be followed by a presentation of th e find ings from the literature
analysis, a discussion of the findin g , and fin ally, recomm endati ons fo r practi ce, re earch,
and educati on. The chi ef purpose of thi review i to make ava ilabl e a body of evidencebased kno wledge about vaccine hes itancy as it is encountered in primary care- e pecial ly
to family nurse prac titioners who are in a ignifica nt position to in corp rate th i
knowledge into their practice. The followin g background to this topic consider a brief

7

hi t ry f phil
1

u

f opp

phi al oppo iti n and th an ti- a em m vern nt and will ituat the
i6on t

practitioner in

a

inati n within the c nt

t f the pra tice of family nur

anada .

Background

History of Va ine Oppo ilion
th incepti n f

111

pp

riti h- rganized acc ina ti on campai gn in th e earl y 1800

iti 11 t irnmuni zati n ha p r i ted ev n a ad ance t vacc ine were mad

( aint- ic t r

m r, 201 ). lnt r

ting ly, m any f th e

ncem v iced by vari o u anti-

a cin e intere t gr up have remai ned unchanged o er ti me, and th e arg ument aga in t
vac in ati 11 ha

impl y hifted th ir [! cu fro m 11e acci ne t ano ther . aint-Vic t r and

m r (20 13) in th eir on id ra ti n of th patt rn of vacci ne re fu a l, note th at over th e
pa t two centuri e , vaccine d i id nt t nd to in i t tha t th eir fir t-ha11d e p ri en ce of
II1Jun ou

acc inati on prov ide a uffi ci nt ba i [! r th eir oppo iti on. ln th e p a t, a in th e

pre ent, tho e oppo ed to accin a ti on appear to g ive m ore we ight to per ona l narra ti ve
and hear ay acco unt , and le

weight to re ea rc h- even re ea rch th at co nsid er th e

potenti al adver e effects of vacci ne and give

m e uppOii to th e posi ti on o f th o e

opposed to vacc in ati on .
Similarl y tho se oppo ed to vaccin ation are also m ore li ke ly to end or e the
viability of altem ative m edi cine as a m eans by whi ch immuniza ti on can be effected . T he
persistence of thi s pattern of opposition over tim e would eem to indicate th a t vacc in e
oppos ition i a cyclical phenomenon w ithin a popul ation , and i not a new i u e in
hea lthcare today. Und erstandin g this trend could help predict w hen th e e viewpo int w ill
eventually fall out of favor .
Histori cally, predictabl e trend s in anti -vaccinati on sentim ent have been hown to
proliferate durin g the time in whi ch di sea e incidence i at it lowe t.

a int-V ic tor and

8
m r (20 1 ) n te that "th peri d f tim during whi h di a
cap publi n ti

n ugh t
pre entabl

fall ut f public n tic

attenti n" (p. 2). Th y a!
bee me le

c rr p nd t a pik

f va

pr val nee rem am

w

ine refu al a va em gamm r

and p t- a cin adv r

p int ut that hi t ricall y th e anti- a me m

em nt

p pular and I e momentum wb n p pulati n e p ri nee a r n w d
and utbr ak or ep idemic re ult. By

contra t, and unlike thi hi t ri ca! tr nd, recent evid n

indi ate that, d pite

wid pread utbreak in 20 12 f p rtu 1 in Wa hington tat - a geographical area with
low vaccin uptak due to a cine r fu al- th ere wa no increa e in vacci ne uptake one
th epidemic ub id d (W If,
finding

pel,

ell art,

arren,

Rowhani-Rahbar, 20 14 ). The e

ugge t that th re are characteri tic pa1iicular t m dem -day phil o

phical

oppo ition that act t reinforce the c n icti on of caregi er de pite th e occu rTence of
epidemic ofva cine-pr ventab le communi cab le di ea e wi thin thei r commu ni tie . Thi
divergence from the hi t ri a! trend de ribed above ignal a ne d for innovative
approaches to o ercoming vacci ne he itancy, espec iall y given th re ilient convictio ns of
tho e oppo ed to vaccinati on in the face of evidence to the co ntrary.
Mo dern Day Philo ophical Opposition

The most recent wave of anti-vaccine entim en t ha been largely attributed to a
controversial study published in The Lancet in 1998, which sugge ted a link between
autism and the MMR vaccine for meas les, mump , and rubella (Gerber & Offit, 2009) .
Autism is an idiopathic condition that has become more prevalent over the pa t 40 year ,
and linking the MMR vaccine to the increa e in the occunence of auti m not only cau ed
tremendous public outrage (Mnookin, 201 2), but MMR vacc ine uptake in developed
countri es fell significantly a caregiver perce ived a ri k of triggerin g auti m in their
children (Larson,

o per,

kola, Katz, & Ratzan, 20 11 ). ln the aft m1ath of thi

9

worldwide att mpted t r plicate the
re ult - with n

u ce

(Immunizati n

ti n oaliti n, 200 ).
I

Anti- ac ine ad ocat
a em pr

hav a!

linked auti m t thim r a! , am r my-derived

nn cted t a 1999

. Thi claim i

nit d tat

d and Dru g

dmini trati n recomm ndation t rem v thimer al fr m infant vaccine a a pur ly
pr cauti nary m a ure ( ent r D r

a e ontrol , 20 J4). Anti -vacc ine advo ate

linked the reported incr a

f auti m with the in crea e in th e number f

accm

in the childh

d a cinati on chedul , and c nclud d that th g vernm ent ac ti n
d th at the pre erva ti v wa re pon ibl e

t r m v thimero al fr m immuni za ti
for the de el pm nt fa uti m (Mn
ub equenll y led th r gove rnment

kin, 20 12).
l

requ

he in ten ity f th e e all egati n

t that vacc in e manufac turer

vo luntaril y

remov thi ingredi ent fr m a ine [I r infant and children. in ce the removal f
thimero a! from Am eri can infa nt and children' vaccin e in 1999, num rou

ubsequent

tudi e have failed t find any cau all ink between thim ero al and auti m (B

D , 201 3) .

Thjmero a! wa removed from vaccine in

i of

anada in 2001 , even a th e diagn

auti m continue to increase (Briti h olumbi a, lmmunizeB , 20 13; Lar on, oo per,
skol a, Katz, & Ratzan, 2011 ).
A worri some trend in anti-vaccine advoca te ' claim about immuni za tion afety i
the ever-changing nature of the argument again t vaccination, whi ch give the en e of a
moving target. As each new claim conceming the afety of vaccinati on is repmied by the
medi a, healthcare providers are continuall y chall enged to re pond to arguments again t
vaccination, and the demand for research to demon trate th at vaccine are indeed afe
increases . Re earch required to counter the oppos ition to vaccination do e not come
without a cost, patiicular ly when un ub tanti ated arguments again t vacc inati on continue

10
t pr lifl rat

and wh 11 th

that the e argument ar

wh ar va em - pp
r-cha11ging (

rb r &

d are unwilling t a know! dge
ffit 2009) .

Factor Contributing to Mo dern-Day Publi M i tru I of Vac ine
o 10- ultural

han

Jth ugh there are imilariti

betwe 11 hi t ri a! and curT 111 phil o phi al

oppo iti n t immuniza ti n, a numb r f
influ 11c

urce propo e that urT nt

11tribute t th pre nt ph e11 men n f increa d pp

cr - ultural

iti on ( ub ' t al. ,

201 3). J ll ey and Dougla (201 4) in e ti gated th e pot ntial im pac t of anti -vac in

con piracy beli ·f:

imilar t th

e linki ng accin e to auti m. T h ey ~ und that

po ure

to anti -vac ine c n pirac th ori e app ar to trigger undue u pici n ab ut vaccin
afety and in rea e feelin g of p w rle n
time d crea ing tru t in auth riti

and di illu i nm nt, whil e at the ame

, whic h in turn introdu ce a relu ctance to vaccin ate.

They a) o linked thi phenomenon to an ver-grow in g" ulture of co n pirac ism" where a
mi tnt t of cience and a di like of medi cal "offic ialdom" tri ckl e down to innuence the
deci ions caregive rs make about th hea lth of their children.
Postmodernism

Alternatively, a number of tudi e propo e that present-day phil osophi ca l
oppo ition to childhood vaccinati on is due le s to a "culture of conspiraci m" and mo re a
by-product of the po tmodern medical paradigm. The argument i that, in a po tmodern
society, as power hifts from provider to patient , the legi timacy of science i put into
question and expertise is redefin ed (Lar on et a!. , 20 11 ; Kata, 20 12) . In this context,
patients are characterized as "consumers" of health care who, w ith their eemingly
limitl ess acce s to online sources of information, are les inclin ed to rely on the "e pert ''
who previou sly helped them navi gate their trea tm ent choice (Kata, 20 12) . Patient today
are encouraged to be well-informed and are increa ingly empow red to contribute to

11
r lating t th ir health · th re 1 a gr
t g ther

qu al

n making deci 1 n

he urr nt tr nd ~ r health are deli

ith th ir h alth are pr

appear t gt

mg mpha i

eight t th per nal alu

ty n w

f th e pati ent a it

and pr fer n

d e t e iden e-ba d medi cin e.
In thi

nt

t, tb p tm d rn c n ept f "r lati i m" d cribe a departure f

b li ef in bj cti e fac t in fa
2 12) . Thi

ur of multiple meanin g and

hift t \ ard multipl e mea nin g

and ge n rali zed u pi i n f
pert-t ha

hifted t

ienttfi e iden
f i n~ rma ti

n urn r tran fe r

an al

a

f kn wing (Kala,

be a c mpani ed b di J!lu i nm ent
hat nee wa a t p-down,

and e p rt1

n with re pe t t th e im p rtancc f acc inati n

ard a n n-hi rar hi al, d tal gue-ba ed pattern

fh n z nta l

n (Lar n et a!., 20 I I . The ant i- a cmatJ n movement ha b ne fited from
thi

ietal paradi gm hift, all wing it n t nl y t

but to al o pi a e th

trength en and leg itimize it claim ,

an u claim t altern ati e or anecd ta l ev idence on par with ( r

ha in g more w ight th an)

ientifi c e idence. areg tver who ub cn be t antJ -

vaccinati n propo iti on are a good diu trati on of thi

hift

in th ei r readin e

to

co n ider th em elve e p rt in th eir children' care, and to take re pon ibi lity fo r
condu ctin g th eir own re earch, often by way of the Intern et in order to make what th ey
co n ider to be inform ed ch ice ab ut the ri k and benefit of vacc inati on.
Media
To further inten ify th e i ue f elf-a ppointed ex pert i e, caregiver are ubject t
inundation by constant media input on qu e ti on of vacci ne afety and effecti vene . Kata
(20I 2) notes th at, with the tran iti on to " Web 2.0," and th e emergen e ofu er-g nerated
Intern et content, ources uch a bl og , video- up! adin g, and oc ial medi a ite have
come to dominate how parent
gr up have made grea t u

hare and acce

h alth inform ati on.

nti -vaccinati n

f th intera ti e nature of thi iterati n of th e Web, all wing

12
ocial m dia to thri e and pr
with a gr up that har

ide an ffecti em an by which indi idual can interact

their b 1ief: and ane d tal eviden e with re pe t t va cme

a[i ty .

hapman and Lea k (2002 , in th ir e aminati n f th

tent and

character of anti-vaccination ite ac e ible n the lnt m et, found that 4 % f the
w b ite that came up when earching [! r "vaccinati n" and "immuniza ti n' c nveyed
iew that w re philo ophica lly oppo ed to acci n .
anti-va ci n web ite i

ften the infonnati n pr du e d by

tra agant and highl y rh et ri a!, de igned to appeal to tho e

with already well-formed vi w a w II a being de igned to de el p a rapport with
parent

eeking vacci n -relat d in~ nnati n

hapman ,

Lea k, 2002; H aly

Pick ring, 2 1 I ). It i difficult~ r caregivers t

ignore the power of th em ti onall y driv n m
which often t reground a parent'

oft n by way of video up! ad ( avie ,

age

n anti -vacc in web ite , ite

tn1ggle wi th a vacci ne- inj ur d child .

It is a! o intere ting to note that anti-vacc ine web ite often have official- oundin g

names that purp ri to be authoritative, uch a the
the Vaccine Risk Awarene

ati onal Vaccine lnfom1 atio n enter,

etwork, and tb e Vaccine Jnform ati on

etwork. areg1ver

usi ng tbe Internet in hope of finding a balanced pre entati on with re pect to the risks and
benefit of vaccine are made vulnerable because th e e ite prey on ass umptio ns that
seemingly authoritative sources will pre ent an unbiased repre entati on of th e fact
around immunizations. On entering these sites, readers are bombard ed with fear-ba ed
messages repmiing adverse effects and images of vaccine-injured children. The
emotionality of these websites, and the way the information i delivered , i p r ua ive to
say the least. Studies have found that only five to ten minutes spent on a web ite of thi
nature is ufficient, not only to alter perceptions but al o to effect a decrea e in tbe
acceptance of vaccine where a previous pro-vaccine stance may bave e isted (Bet ch,

13
R nk witz, B t h ,
u

ptibl t

1 h .. D r 20 I 0) . ac 111 -be itant car g1 r are parti ularly

uch w b ite a they att mpt make an inD rm d de

ion t immuniz their

mbin ation of p udo -offi ciald m with m ti nal fear-ba

children. Th

diffi cult t ignor wh n a ca regi

r ha their hild ' b

d m e age

in mind .

E 'P riential Kn owled e
ln th e light f

emingly limitl e

and c ntradict ry ource

f vacc in

inD rmati n, it i belie ed tha t m any h alth are pr fe ional hav undere tim a ted th
p r ua 1
p en n

natur of Jnt m t anti - ac in e m
with illn

and di r gard ed th e p wer of par nt '

ag

e in th eir c hildren (M cMurTay et al. , 2004). Re

when communi ca ting w ith ca regi er wi th re p

tt

arch how tha t,

th e ben fit of vacc inating th eir

children health ar profe ional tend t emph a iz r earch th at indica te a redu cti n in
the in id en e f di ea e in hi g hl y acc in ated popul ati n (H a ly & Pi ckerin g 201 0) . Thi s
ob erva ti on i

ignifi cant w hen co n id erin g th at t day' ca reg iv r may never have

experienced or w itne ed a va cin e-pr ventable illne s, but th ey are like ly to know of, or
have a child of th eir own, di agno ed w ith a di ord er th at ha been impli ca ted in th ant ivaccin e di cour e, uch as an auti m spectmm di ord er, juvenile autoimmune di sease,
attention deficit di order, or a n atopic di ord er. Anti -vaccine website have linked all of
the e illnesses to routin e infant and child vacc ination s ( ati onal Vaccine Infom1a tion
Center, 2014 ; V accine Informati on

etwork, 2014).

Re earch indi cates th at first-hand experience w ith children w ith auti stic di sord er
plays a n influenti al rol e in parental deci ion not to vacci nate their child (M c Munay e t al. ,

2004). Cunent recommendations with res pec t to communi ca ti on strateg ie for
encouraging vaccination do not, for the mo t part, ackn ow ledge the influentia l role th at
experi ential knowl edge plays in the dec ision-makin g proces e of caregiver . Nor do
the e recommendation take into con siderati o n th e ex t nt to whi ch parents are chall eng d

14
by th

a tam un t of c ntradi t ry infl nnati nth y fl el blig d t

appra1

in rder t mak th b t h altbcare deci 1 n

urr nt Va cine H e itanc
Int r

n t al. 2004) a ignifi cant c ntributing

itan y i th edu cati nal m d 1 t which health care pr v id er adh re

ing the t pic f immuni za ti n w ith the ir pati nt .

wh n addr

th a t mu h o f the educa ti onal m ate ri al d
to addr

n b half of their childr n .

Irate 1e

tingly a c rding t Fredri ck

fact r to vaccine h

th

ift through and

acc inati n c nc m

numb r f

urc

no te

el p d t ad i e h althcare provid r a to how

f patient ha it ba i in a " c gniti ve d fi it" 111 de l

(Bl nd II & Fehr, 20 12 · Fredrick

n e t a!., 2004 ; H aly

2011 ; K enn dy t al. 20 11 ; M e

urray et al. , 2004 ). T he cognitive defi cit m o del a um e

th at pati ent

Pi ckering, 20 11 · K emp e et al. ,

impl y Ia k th medica l fac t needed t make infonn d deci i n about

vaccine , and th a t th e prov i i n f 111 d ica l infmma ti o n w ill, in it e lf, be uffi c ient t
quell acc in e co ncem . At pre ent th e edu ca ti ona l re ourc
prov ider by th Briti h

olum bia

entre fo r Di ea e

d vel ped for hea lth ca re

ntro l (Immuni zati on

ommunica ti on A K Too l) and th e Pu b li c Hea lth Age ncy of anada ( anadi an
Immunization Guid e) to addre

vacc in e he itancy pl ace great emph a is on cou ntering

anti -vaccine argu ments w ith evidence-ba ed in fo nn ation th at purport vaccine afety
(BC DC, 20 13; Publi c Health Agency of Ca nada, 20 13a). K emp e e t al. (20 II ) argue
th at thi s traditi onal approac h to pati ent edu cati on has hampered th e efforts of primary
care providers to addre s vaccin e hesitancy or refu al. Research coming out of the
behavioura l science fi eld proposes that, to effective ly addres vacc in e hes itan cy ,
hea lth care professiona ls must take into account the reality tha t caregiver deci ion-m aki ng
is influenced by the wider socio-cu ltural contex t, not impl y inform ation from a in g le
(m edi cal) ource. (Du be et a l. , 20 13).

15
Wh n c mpann g urr nt ac m commun 1 ati n trat gi
fram w rk u ed for thi r

t th th

r ti al

i w it be arne ev ident that the fu zzy- tra e the ry

uld

pro id rati nal a t why thi approach ha be n un ucc
2001 ). The fu zzy trace th
pro

ry pr

ide a wa

ful ( rainerd & R yna ,

flo king at the vacc in d i i n-making

ba ed n h w inft nnati n i imparted, eith er thr ugh i t r v rbatim

repr entati on (Reyna, 201 2) .

rb atim r p ·e ntati n make up th

inft rmati n hea lth ca r pr vi d r

hare with their patient regarding acc inati on

H althcare pro ider may c nc ntrat their ef[i rt
accination t caregi er , al ng th lin

vid n e- ba ed

n rep rting th fac t r gardin g

f the c gniti

d fi ci t m del, rath r th an b mg

concerned with ac tuall y impa rting mea ning along wi th th e in[! rm ati n. Thi may ex pl ain ,
m e tent, wby tbe
deci i n-making pr c

gni tive defici t m de l i n t appropri ate for the com pl ex
th at car gi er are confronted wi th when attempting to prov id e

the be t car £ r th ir cbildr n. Furth r ex pl anation f the fuzzy- trace th eory i provid d
later in thi re iew, along with a di cu ion of the way it can be appli ed to the findin g
revealed by the literature.
A noted above, a certain mi tru t of offic ial cienti fic infonnation is
characteri tic ofp o tm odem oc ietie (Lar on et al. , 20 1 I). Much of the info rmation
about vacc ine safety currently provided to healthcare professio nals is di tribu ted by
govemment agencie and medical ocieti es, ource that likely fall under the ru bric of
"officialdom," and could therefore be suspect in the perception of vacci ne-hes itant
caregiver . By using information provided from offi cia l sources, such as Hea lth Canada,
the anadian Paedi atric Society, or the Centers for Disease Control, healthcare provi der
are not taking into account research that indica tes caregiver who are likely to be hesitant
or refu e vaccination are al o likely to mi strust uch authori tie (Lar on et al., 20 11 ;
almon et a!. , 2005). Providers who endor e the e offi cial sources to their patient in the

16
ur
t

f addr

tng vac 111 h

itati n may find that th c nten t of what they are trying

ay fail t engage va cine-h

itant ar gi er , gi v n th e la k f tru t thi populati n 1

r p rt d t ha e in formal auth riti

f thi natur

Vaccine Oppo ition: M ultiple Determinant
en the multiple fac t r that app art inf1u nc
fac t r her a a

it i w rih e ttin g ut th
hea lth ar pr

unt th e m any fac t r that current]

careg1 r . T he author
di cu

d with whe n it om

t r e tabli bing a

ub e e t al. (2 0 13) propo e a c nc ptu al mo del for

und er tanding acc in e he itancy that w ll c n e
int a

itancy at thi time,

ay f illu trating th c mple ity tha t

ide r and o ia l c i nti t ar fa

better rate [vaccin a ti on .

accine h

th e

m pl e ity f thi i su e a nd take

influ ence th e de isio n-maki ng proce e

f

xplain th at " thi m ode l wa ada pted fro m a che ma umm ary f

ions he ld during a w rk h p n th cultural and reli g iou roo t of vacc in e

he itancy in

anada' (p . 1763). T he work hop wa pa rt of a onference at th e

ni ver ity

of herbroo ke th at addre ed acci ne he itatio n a nd inc lud ed e pert fr m soc ia l sc ienc
humaniti e , public hea lth , and bi m edi ca l sc ience . T he auth ors argue th a t vacc in e
he itancy i ac tu a ll y are ult of broa der oc ietal influence th at in cl udes hi to ri cal,
political a nd socio-c ultural co ntex ts (Dube et a l. , 201 3) .
The workshop parti cip ant determined th a t a compl ex an ay of bo th ex terna l and
intern al influences govem the individu al choice of wheth er or not to vacc inate. A chem a
summ ary was develop ed out of th ese discu ions (Laberge et al. , 20 11 ) and wa later
developed as a conceptu al model that depic t th e w id e range of influence to w hi ch
caregivers are subj ec t to , and situ ate th em on a spec trum that range from refu a l t
acceptance. Appendix B , Fi gure 1 presents the m ode l that came out of th e chem a
developed in th e workshop . This model ha implica ti on for PCP becau e it indica te
that vacc ine hes itancy cann ot be attributed to a imp I Jack f inform ati on, or to an

,

17
r upp ly f bad in~ rmaU n. It plac
ci - ultural c nt

th e i ue f a ine h itancy within th wid r

t and map a wh 1 range influ nc

e temal t th pati nt-pr vider

r Jation hip . Thi d pi tion f the r ality that ar gi er are ubj ect t ha the p tential to
hap the way in which healthcar pr fe i nal addre

vaccine-he itant pati nt ,

e pecially giv n that cutTent recomm ndati n

-D rin-D rming car giv r

pl ac greater

empha i on the imp rtan

id r relation hip . on id rati n f

hi t ri ca!, politica l, and

wi ll und ubtedl y h lp hea lth are provider

b tt r und er tand that thei r patient ar moti a ted by a br ad range f e lerna! factor ,
and d not imply ac t on the ba i

f tru t.

Canadian Vac ine R equirem ent

Walkin haw (20 11) n te th at in anada, three provinc
vaccinati n p 1i i

ha e legi Jated

that app ly t children preparing t enr II in chool:

ntari o and New

Brun wick require immunization agai n t diphtheria, tetanu , polio, mea le , mump , and
rub ella and , in Manitoba proof of a rn a le

acci nati on i required before children

commence kindergarten . De pite thi mandated requirement, all three pr vi nce also have
legi lation that include an exempti on clau e. According to Walkin haw, thi al low
caregiver to requ est that th eir child be exempted from th e vacc in atio n requirement n
medi cal, religiou , or conscience grounds. At pre ent, no oth er province in

anada

require proof of up-to-date immunizations before entering choo l (Gilmour, Ham on,
Asadi, Cohen, & Vohra, 2011 ). This tate of affair in Canadian choo ls mean that there
i no way of knowing how many children in any given schoo l popul ation are lacking
recommended immunizations.
Smith, hu, and Barker (2004) examined the socio-cultural attribute of both undervaccinated and unvaccinated children between the ages of 19 and 35 month in hope of
predicting trends in the U . They found that under-vacc inated children- who typically

18
ha e om , but n t a ll a

inati n up t dat - be lon g to a racial minori ty, have am th r

wi th a low du ati nal tatu , and be l ng to a b u

h ld liv ing b I w the po

ti y lin

n th otb r band, th y ~ und that un ac inat d c hildren had caregiv r wh w re
d · they tended t be

auca ian , ha e a m ther w ith a co !J ege edu ca tion ,

li e in a h u eh ld with a c mbin ed in com e e

eeding 75, 000 , andre id e in an urban

tting.
Re earch th at

a mm

th e i u

f und r- acci natio n t nd

r m o ing of barri er t hea lth care ac e , and ad o ate

trateg ie t r mind careg iv r

th at a c in a ti n a re du a a way t incr a e vacci n uptake .
in

a nada do not r quir pr

f f im muniza ti n pri r t

to a ceJtain th e I ve l f r i k tha t hildre n in a ch

D cu. on th e i ue f

iven th a t m

t p rov ince

choo l en ro llm ent, it i diffi cult

I p pul ati n face w hen un vacc in at d

and und r- accinated childre n are large ly un ac ounted for. T h i i a n imp ortant
con id ra ti n w hen m ed ica l ly-e
to illne

mpt children- w ho are un ab le to rece ive vacc in es du e

or all erg ie - pl an to att nd a cho 1 w here the ra te of vacc in a ti on in th e

population i und etermin ed .

areg1ver of the e children, un abl e to ri k vacci nati on, are

face d w ith having to mitigate the ri sk of expo ure to communi cabl e d isea e in the
absence of knowing th e rate of vacc in ati on in th e choo l popul a ti on .

Philosophical Opposition and Primary Care
Philo ophi cal opposition to vacc in ation pre ents both a chall enge and an
opp01tunity for P CP s. Once an issue re lated onl y to th o e worki ng wi thin the public
health sector, the issu e of vaccination has more recentl y moved into the ph ere of primary
care. This is in res ponse to the twin na ture of vacci nation a both a publ ic hea lth program
and an indi vidua l preventive in terventi on . Today , both primary care g ivers and publ ic
health ca re agenc ies have a decid ed interes t in th e w id e pread de li very of vaccination .
There i strong ev idence to indi ca te th at P P play an influ enti a l rol in th deci io n-

19
t whi h ar gi r ' mbark on during vaccinati n d ci ion-making,

making pr

n wh r the primary are pr

id r i n t pr

mith tal. , 2006 · Fr d, lark, ut hart
mer tal. , 200 ). h pr en
lik ly that 1 rimary care pr

f an

iding the va cine (Mergl r tal. 20 1 ;

mger,

a i 2011 ; aim n t al. , 2005;

tabli h d r lati n hip eem to make it m r

id r will be appr a h d D r vaccine-relat d inD nnati n.

Whil e att nding in idental app intm nt with a prim ary ar pr vider, the pportunity to
di u

whether r n t a child i up-t -dat on th eir immun izati n i alway ava il abl .
ln pite ,f th e ev id n

impli atin g tb e rol

f th primary hea lth are provi der in

th deli ery of accine-related in~ rm ati n, much f th e r levant edu ati nal in~ nnati n
devel ped in

anada i de igned t addr

that P P are n t a awa re of the e re ourc

all health care pr vider . Howe er, it may be
and/ r d not refer t th em a frequ ntly a

other healthcare provider , uch a publi c health nur e do (B

0 , 201 · Publi c H alth

Agency of anada, 20 13a) .
In Briti h

lumbi a, mo t infa nt and children receive their vaccinati ons at pu blic

hea lth clini c by way of schedul ed appointm ent with a publi c hea lth nur e (Pr vincial
Health ervi ces Authority, 201 2). The potentia l for caregivers to develop a relatio nshi p
with employees at public hea lth units depend on the community, it popu lation, the ro le
of the taff empl oyed there, the tructure of the cl ini c, and how long the fami ly ha
resided in the area. Given that most children in the province rece ive their immuni zati ons
at public health clinics it is intere tin g to note that the official edu cati onal materi al
promoting the importance of vaccination i targeted for hea lthcare providers in a etting
where hesitation or refu sal may be less likely to occur (BCCDC, 20 13; Publi c Health
Agency of anada, 20 13a) .
It i also important to acknowl edge that vacc ine-hes itant caregiver can ea ily

avoid appointment at public health clini c and thereby thwart potential di cu io n. about

2

a inati n, r

ap entir I fr man pre ure t immunize in th

app intm nt. Th

h i

implc

t n tb

mparcd t th pr

wh nit c me

ur

[ th ir

k an a1 p intm nt with a publi hea lth agen y i

pect f ta ing ff th radar b

ir um enting primary are

h1ldren.

hi i n t t

a that re urc

ha

b en mi dire ted in train ing pu bli c h alth

nal t appr pri atel addre

th e

n em

\ ithin the tru turc f th
edu ca ti nal

ntent; th

a
P

urrent h alth

in c-he itant par nt . Rath er,

r \ ell-pi a ed t deli er

hav b th th e pp Ji untt and th 1110u n e to wo rk with

a cin -he itant careg i er de ptt th ctr le

r r le 111 th e a tu al adm ini trati n f

ace me
In rd er t c m
pnm ary are pr
into account. R tr

an un der tandin g f th e ltn k b twee n a

ider , b th retr

pec t1 e and pr

ine he itan y and

pecti e on idcrati n mu t be taken

p ti el P P , pec ifi ca ll famil ph y ician , ha e been criti ci7ed

D r their auth ritaria n tance, a beha i ur th at i
vehemence of th e anti -va cine m ve ment.

een a a co ntn butin g fact r to th e

uk (20 J 0) argue th at th e der ga t ry and

conde cendin g rh et ric th at charac teri ze th e medi ca l literature th at e amin e vacc meoppo ed parent - along with the hi tori ca l legacy of patem ali ti c behaviour n the part
of th e medi ca l ommuni ty- could be a fac t r in th e increa ed ppo 1tion t vacci nati n
He point out th at long-term benefit are to be had if we addre

th i and move to build

partner hip with parent a indi vidual rath er th an trea tin g th em as part of a group th at
exi ts in oppo iti on to medi cal auth ori ty when it come to vaccinati n. Pr
primary ca re is m ving toward

[i

pecti ely,

terin g partn er hi p between provider and pati ent

when it come to making deci ion with re peel to th eir hea lthcare- a hift th at co ul d
we ll impro ve th e balanc of thi relati on hip .

21
ltrnati el
n th primar

b tw

ar pr

id rand the pati nt and th
f p1111 n

ith a fund am ntal dif[i ren

d

ith tb nature f tb relati n hi t

ifthc urrenti u ha littl e t d

eemm g unpa

ith re p t t

a cinati n , wher n itb r
care, n n-adh r n

party i willing t

n de what i th e n

t p . ln prim a

pr

mm npla

. Pati ent ar

~ r th

mpliant

ith th e r

ider ad tc

1

ithcr

d

id r

ntrary t

r

and e mingl with ut th c ntr

ab ut a

in ati n .

rdin g t

m

cr

id r and ar gt er apprat

at th e e"

nt ted n ti n

n k fa

f n k" (p. I 0

to

t part fr

make their wn

mmend ati n

th eir prim ary

and em tt naltty attac hed t

a id (2007 , what eparate

h itanc fr m th cr bcha i ur ar und n n-c mplt an
pr

ba

a Cllle

th e di fferen e in h w

r related t certai n d

'a id y I

k

) tn th e li ght f th e MM R c ntr ver y (noted

ab

). h find th at aregi er are fa ed wtth a

of a

inatin g ver u ha ing th ir hildren

r qui rin g th em t make a jud gme nt ab ut ri k

in g th e p tent iall y

mpetin g ri k

ntra t a acci ne- preventab le di ea e,
n b half

f th eir htld .

In contra t, ~ r e ampl e, if a P P di cu e th e ri k and benefit of a vega n diet
with a caregive r c n idering thi

pti on forth ir child , b th th e pati ent and the pr vide r

under tand th at the di cu ion c ncem onl y the child ' be t hea lth intere t . ve n if the

P P p int out the inh erent ri k of a vega n di et fo r a grow ing child, th re i u ua ll y
ro om for both parti e to work togeth er to determin e whi ch vega n food produc t are mo t
appropriate. In the e ituation , the P P i generall y ab le to ace mmodate th e car giver'
beli efs and en ure th e co ntinued hea lth of the child .
What differenti ate ri k/benefit di cus ion abo ut vacc in ati on i ab en

of r

m

for di sagreement between both parti e and th e extent t whi h th e di cu ion tend to b
po lari zed. At ne ide, he itant ca regiver are likely to argue th at th ere i

id n e t

ugge t that th e ri k of adver e effect fr m acc ine are grea t r th an th e b ne fi t of

22
pr t cti n fr m the di ea

d

n t

kn wl dg
mpam

t th high

, hould they c ur. They may al o u p

t pri rity n the hild ' b

fth ri k i limit d, r
or go

tak th po iti n that e

lu i n fall

p p

tint re t

m e fr m dubi u

mm nt publi c h alth ag n i .

t that th ir P P

urce

u h a pharma

uti ca!

t the th er id e, P P are lik ly t

r any of the ac inati n in the r utine childh od

chedule wi ll plac both tb child and the communi ty a t ri k for ontrac tin g a
communi cab! di ea e; th e ma a!
ar n t upp rted by cienc .
c m

add th at th argum nt of ant i-va cine advocates

he lack fa c mm n gr und b tween the two w hen it

to th e topic of ac ination pr ent an un tab le plat~ rm o n w hich t build any

kind f meaningful ri

b nefi t c mmunicati n, I t al net pr p

e that th e benefit

outw igh th e ri k .
A furiher compli cati n in th delivery f primary care, when it c m

to

non -co mpli an ce with vaccina ti o n, i th e d minant r le caregiver play a heal th car

deci ion-maker for th ei r d pendent hildren . P P may hav a cetia in level f comfo ti
around non-compli ance w hen the perceived ri ks apply only to the patients them elves.
However, when ri k are ee n a being imposed on depend ent childre n or on vulnerab le
m em bers of the wi der comm unity , a wi th vaccine hesi tancy, P P report having felt a
sense of frustration and anger w ith caregiver dw-in g th e con ultation proce

( Lyren &

Leonard, 2006). According to some sources, when this happens, the primary care
provid er might even choose to di miss the family from the practice when it eems that
trust in th eir professional recommenda ti ons has been threatened ( ilmour et al., 20 11 ;
Lyren & Leonard, 2006) . PCP in Ca nada are, however, encouraged to u e their influ nee
despite their frustration or worry on b ehalf of their you ng patient , to work w ith vacci nehes itant caregivers on the ba is of evidence that shows that their profe ional advice
carri e some weight (MacDonald & Fi nl ay, 2013) . v n in th e face ofve h ment vaccine

2

r fu al th id a 1 that thi kind f w rking r lati n hip lea
futur

pp rtuniti

patient-pr

p n the p

D r meaningful di cu i n and demon trat

id r r lati n hip

an b built n re p

ibility f

ar g1v r that

t and kindne

despite a differenc of

pini n ab ut immuni za ti n .

Philo ·ophical Oppo ilion and ur e Pra titioner Pra ti e
n integral part of e ploring thi r
nur e pra titi n r ( P) pra ti e, and t
nur ing. Tb link bet

en th

e tabli bed her . nd , gi
infant and hildh
1

u

d

the pr ce

dif~ rentia te it fr

n federal and pr

ccine uptake,

incial tali tic th at indi ate I w lev I of

P a P P wi ll ine itably have to add re

the

ur e ftheir practi e.

lumbia th re i al

a we ll -e lab li hed link betw en

of vaccinati n. De pile th gr at r rol

of vaccination

m th r alm f public hea lth

ac ine h itati n and th role f P P ha b en

fvaccin he itan yi n the
In Briti h

ar h qu ti n i to hi ghlight it c nne ti n t

P practi e and

f public hea lth in the ad mini trali on

P are till enli ted to pr vide immu ni zation in the pr vmce,

particularly in rural and rem te cli ni c (
( RNBC) 201lb; Briti h

!lege of Regi tered

ur e of Briti h olumbia

lumbi a Immuni zeS , 20 13). Here, vaccination

appointments provi de opportuniti e for vaccine-he itant caregiver to di cu

the e

concern with their primary care provider.
There is some evidence to indicate that the bu y office chedule of prim ary care
physicians and pedi atrici ans impose a banier to tho e wanting to discu

their

re erva tions around vaccination (Kempe et a!. , 20 11 ). ang ter- onn ley (20 12), in a
survey of NP practice patterns in Briti h olumbia reports that the mean number of
patients seen per day by an NP i 14. Herre ults ugge t that NP workin g in primary
care practice may have more time to pend with each patient, and will thus have

24

additi nal pp Iiuniti
t

a

[! r educating th ir patient and initiating di

u

n with r

pect

ination .
P ar w 11- uit d t addre

th i u of a

i n . Research indi ate th at th y

having b th the tim and pp rtunity D r th

di

ar w ll -placed t

ine- re la ted di cu

hare r

th r nur in g-re la ted pro fi

p n ibilit for a

i n , a itu ti n th at

larger i ue fin r a in g a cin a ti n ra te (

u

ina ti n , quite apart fr m ju t

uld w II b benefi ia l in tacklin g the

o d-Harp r, 2 05 .

practi ce- gr unded in pa tient-c ntere , h li ti nur mg are
w hen addre

ing th t p1c

[ a

i n w ith pb y ic ian and

h na tur

may we ll be a dva ntage u

inati n wi th caregi er . K enn edy,

(2 00 1) con Jude th at a h li ti a pproac h i need d to addre

a k t and

ccording to H amri c,

th e ho li ti c per p cti v in direc t c lini ca l care invo l

heedy

accin e he ita ncy, an

appro ac h th at hinge on the parti c ul ar abili ty f a h a lth ar pr v id r t addre
re lated co ncern in an appr pri a t way .

r P

pr

vacc me-

, and H and on (2009) ,

" a d ep und er tandin g of eac h

patient a a compl ex and uniqu e per on w ho i emb edd ed in a temp orally un fo ldin g life"
(p. 126).

Primary care nur e practiti oner in Briti h

lumbia have th e mand ate to practi ce

fr om the per pective of holi ti c nur in g, and to parti ci pate in initiati ve that p romo te
health and redu ce the ri k of compli cati on , illness and inj ury fo r their individua l c li ents,
client group s and/or the population a a w hol e (CRNB C, 201 1a) . T h i em phas is w ithin
the scop e of primary care lend itself well to m akin g a pos iti ve contri bution to increa mg
th e awareness of vaccin e benefits where vaccine he ita tion is invo lved .
Thi s proj ec t examines both experimenta l and no n-ex perimental re earch w here
intervention s have been proposed as a way of respondin g to vaccin e hes itancy. T he
relevance to and impl em entation in primary ca re prac ti ce i di cu

ed with a iew to

a sisting NP s working with caregiver w ho are vacc in e-he itant, w ith th e goa l of

25
increa ing immunizati n uptak . Th ugh thi pap r i primarily intended t b u

ful t

P in primary ar pra ti e wh are lik ly t w rk with car giver to infant andy ung
rel

chi ldren, the recommendati n ar n n th el
nur

wh

p diatri ian

pr

ant to primary car phy icians,

ide ar t infant and childr n in b th publi c and acut care etting ,
and midwi

T heore tical Fra mewo rk

F uzzy- Trace Theory
Th fuzzy-trac th e ry a outlined by
re iew of evidence and pro id

th

ra in erd and R yna (200 l ) guid e thi

re ti ca l frame\ ork -f r making en e of the findin g

g l aned from th literature . T he fuzz -trace the ry (F T) a ttemp t t d mon tra te th e
way in which cogniti n draw upon dual m nta l r pr entati on - gi t and verb atim

to

predi ct and e plain c gniti v phen mena, pmiicularly in th e domain of memory a nd
rea oning (Reyna, 20 J 2) . Wh n app li ed to th e i ue of vacci ne he itancy, acco rdin g to
Rey na (20 J2), th e FTT pro ide a "proce

m del of how people make vacci nati on

judgment and deci ions ground ed in empiri ca l ev id ence abo ut ri k perception, ri k
communication, and deci ion making' (p . 3 790) . R eyna goe on to note th a t " according
to fu zzy- trace theory any m eanin gful information inputs are a sum ed to be encoded into
memory in two way : a verbatim repre entati on (the objec ti ve timulus or what actua lly
happen ed) and a g i t representation (the ubj ec tive interpre tation of information or
interpreta tion of what happened) " (p . 3791).
For example, verbatim or literal representation encoded in to memory include
exact words or numbers (remembered, ay , as a percentage of illness in a particular age
group when exposed to a particular ri sk) ; Gist interpretations of th ese ame numb ers or
word wil l differ across individual s, given that form of m em01y i entire ly ubj ecti ve and
depend s on everythin g a perso n know , a ll of which will affect they way the interpret

2

rbatim r pre
Iiii e ' P ri en

ntati n
, pr judi

i tint rpr ta ti n d p nd n cu ltur ,

rid 1e , kn wledg ,

and b lief:

na , 201 2.

un unding piau ibilit (R

fa tatem nt f ri kin
w

t

dep ndin g n the I

ntra tin g an illn

kn wn n
b au

in qu e ti n.

tat ment

el f ri k th indi idual making th e judgm nt d

b thr at nin g t th ir hea lth , r n th pri r ' pen en
p ifi illn

, th gi t f thi

th

c n id r th illn e

cau e m rbidit , r d the

in g the

m t

th e indi idual ha had with th
" hi gh ri k" be au e it ha bee n

n id cr th e illne

t be " I w ri sk"

it ha an effe ti c trea tment .
FTT indi ca te th at th gi t repre ntati n f th e inil m11a ti n, rath er than th e

verbatim rcpre entati on, guid

b th h rt and I ng- term j ud gment and de i i n-makin g

gi en th at pe pi ha e a " fu zz -pr ce in g pr feren e" (Reyna, 2 12) . Thi mean th at
pe pi e tend t re ly, whenever p

ible, nth gi t f

r pre entati n- rath er th an a v rba t1m r pre entati n.
repre entati n

m thin g

th e fu zzy r imprec i e

th gi t and ve rbatim

upp ort differin g il nn of cogniti e pr ce ing. Ve rba tim repre entati n

upport prec i , analyti ca l th ught pr ce e where gi t repre entati n

upp ort intuiti ve

proce ing, whi ch i hi ghl y impre 10n1 ti c. Reyna (2 0 12) note th at th e eemin gly
irrational thinkin g around vacc ine can n t be a /ely attribut d t th e leve l of emoti on
inherent to th e inform ati on pre ented on anti -va cine web ite . Wh ile emotio n doe play
a pa1i in fu zzy repre entati on , it i th e meanin g deri ved from th e gi t, not im ply th e
feeling generated by th e expo ure, whi ch co nnect th e dot with input to appreh nd th e
e ence of th e experi ence. Meanin g deri ved in thi way repre ent th e core of how peo pl e
proce

informati on, and then pr ceed to communicate th eir co ncern about the hea lth

in[! rm ati on th ey have proce ed, and thi relate direc tl y to th e way in whi h caregiver
are most likely to make vaccine dec i i n

27
n t dab
w rlong with a
vi den
L

'

ine-h

mu h f th r
itant caregi

r highli ght the imp 1ianc of r Jati nal qualitie ,

mith tal. 200 ; " accme afl ty' 2009) . lt indi ate that th e patient-

pro id r re lati n hip enhan ed by g
mea nin gful inilu n

th re

ate th r le f P P in

-ba ed informati n baring, and p n-communi ati n (H ealy & Pi kerin g, 2011 ;

i 200 7·

li ght n

arch literature that ad

d communi ca tion tra tegie

m ay hav

orne

o n accine uptake. The literature, howev r d e not heel mu ch

hy o ne communi ca ti n tra tegy i likely to w rk be tter than anoth er. Nord e
arch e pl ore why th

ntent f th e anti -vac ine arguments ar m re c mpellin g

than th e info rm a ti on put fl tward by h a lth are provider .
iven th utility o f fu zzy- trace the ry to und er tandin g how dec isions a re made
with re pec t to acc in ati on uptake, and the findin g of thi integrati ve rev iew, it appears
th a t it w uld b h o e hea lth prac titi ner t a ppea l to vacc in e- he itant ca reg ivers thr ugh
different fram e of reference, pec ifi ca ll y one th at stimul ate th e deve lopm e nt f
m eanin gful , pro-va cine g i t re pre enta ti on . The fuzzy- trace theory expl a in s w by th ese
trategie are ucce ful and indica te w hy th ey are relevant to prim ary care prac tice,
research, and edu cation . Thi th eory a lso upp orts the premi e th at the interpretation a nd
ub equ ent m eanin g underl y in g our immuniza tion trateg ie wi ll have an impac t on
increa in g vacc ine uptake .
This paper doe not intend to indica te that th e infom1ati on bared between PCP
and th eir patient with respect to vacc ination is wrong . Rath er, th e chall enge h e in
encouraging PCP to pre ent infonnati on u in g gi t repre entations that in vo ke meaning
that stimul a tes favorable perspective about immuni za ti ons to va cin e-he ita nt caregiver
instea d of simply positing ev idence-based facts that pronoun ce th e safety of accines .
Doing so could prompt an intuitive respon eon the part of the careg iver, one th at would

28

b mor inclin d to upport a inati nand n ourage th b lief that th ri k of
immunization pal in

mpan

n to th ri k of

mmunicable di a e.

29

HAPTER2
M ethod
Th r earch qu
int grati

literatur r

ti n pr p
1

w.

cc rdin g t

revi wing a b dy f literatur all w for a
ample th

ed by way fan

d by thi

hitt m re and Knafl (2 05), thi m th d of
mbination f di

r e m th dolo gie - for

e applied t b th xp rimental and n n -e p rim ntal research- as a trategy

£ r in[! rmin g viden -ba ed pra ti e initiati e . The idea i th at, by examining literature
from a ari ety f ourc

and di ci pline , a r bu t and appropr iate body of inform ati n

can b ga rn ered t b

th ere ea r h que ti n defined by thi pr ~ ct. The

integrati

r

t add re

i w meth dol gy i c n id r d, in thi ca e, a ap r ductive way to identify

evidenc -based trategie that P P c uld find u efu l in thei r att mpts t c nvmce
he itant familie ab ut th

a[! ty of immunization, and ther by increa e th e overa ll

vaccine uptak in th e population . Thi literature review wa und ertaken in four tep : th e
earch trategy wa con eptuali zed, a preliminary earch wa condu cted, followed by a
focu ed earch , an analy i , a nd a di cus ion .

Step 1: Conceptualization and Sea rch S trategy
The fir t tage of thi s rev iew began w ith th e proce

of identifying the con ept

that would best inform the initial earch strategy. Thi re earch was prompted by an acute
awarene s of the need for NPs to have evidence-ba ed intervention trategie to a si t
them in the process of communicatin g with vacc ine-he itant caregiver - in a way that
might lead to increased vacc ine uptake overall. Effective trategies are needed to increa e
vaccine uptake in a population of caregivers where there is alway the ri k of a hift from
vaccine hes itancy to vaccine refusal. It is thou ght that thi ri k is based, in part, on th e
way in which primary care providers re pond to th e vaccine-hes itant caregiver w hen
caregivers ask probing que tion s or convey anti-vaccine viewpoi nts.

30

Thi r
d

ar hi ba

n-making proce

d n the a umpti n that

that caregi

r ar

P a P P can influ nc the

ubje t to when con id ring the aft ty of

a cm

ft r their children . Thi influenc d pend

profe

nal t r c gni ze tea hable m m ent and t anti cipa te wher guidan e i n eel d .

It al

d pend

n th ability

n th ee t nt to whi ch h a lth are profe

f health are

i nal und er tand th e conte

within whi c h ca r gi er live, and thee tent t whi ch they are influ enced by th e
wid

pread public d bate ab ut acc in

afety cunentl y being br adca ted by multiple

m ean . T he ear h trategy wa gu id d by th e qu e li on " Wh at a r the evidence-ba eel
interventi n th a t primary are nur

prac titi one r can empl y to c mmunicate the afe ty

of immuni za ti n in ord er t mcrea e acc in uptake in he itant careg iv r . "Thi review
examm e thi qu

ti n in th conte t f prim ary care prac ti e 111

Th e fir t t p in£ rmul a tin g th

an ada.

earc h tra tegy wa to dete rm ine th e e ligibility

criteri a for the litera ture electi on . ource were re tri cted to re earch tha t co n id ered
tra teg ie to increa e the uptake of infant and earl y childh

d vaccin ati n ; tudi e th at

examin ed th e uptake of vacc ina ti on in o ld er c hildren (e .g ., hum an papill omav iru
(HPV)) were exc luded . vid ence indicate th at parent of o ld er children have di ffe rent
rea on for opposing vacc in ati o n th an tho e given by parent of younger children. For
exampl e, parent can be relu ctant to have immunizati on that protec t aga in t exua ll ytran smitted viru e (e.g., HPV, the hum an papill omav irus) admini tered to their
adolescent children for a numb er of reaso ns (Dem ey, A braham , Da lton, & Ruffin, 2009;
Sturm, M ays , & Zimet, 200 5) .
Thi integrative review con iders a range of re earch th at extend beyond th e
medi cal literature into the domain of th e behavioural science , with the und er tandin g that
perspecti ve coming from th e eli ciplines of ocio lo gy, p ychology, and a nthropology
could we ll provide useful recommendati on for health care when it com es to

31
und r tanding human beha i ur and m ti ation ( ar n tal. , 20 ll ). Th behavioural
nc
qu

are abl t

ti nth

deci

th th intrin ic pr

a~ ty

f a

111

a w 11 gi e w ight t e trin ic fa t r that influenc

n-makin g, uch a cultural backgr und

cial tr nd

oct -dem graphy . Tab] 1 li t th criteria by whi ch
li gibl D r thi r

that m tivate par nt to

ur

political clim ate, and
were con id r d to be

1ew.

Tabl e 1 Elig ibility criteria fo r inte ra tive literatur re1 i w inclu ion

lnclu ion
rite ria

1. ngli h language literature, th at wa publi bed in academi c j
b tw en January 200 - eptemb er 20 14.

2.

rticl that relat t r utin e immuniza ti on chedul e
arty childh od a cine uptak .

~ r infant and

. Re ea rch reportin g accine he itancy or ref1.1 a 1.
4.

p rimental an r n n-e perimental re earch th at rep rt vaccine
r f-u al or h itan y and make reco mmend ati n appli cable to
primary care prac ti ce.

5. K yword that include vaccinati on, tru t, du ca ti on, parent , afi ty ,
compli ance and refu al.
6. Arti cle addre in g practi ce in primary care, nur
phy ician , paedi atri cian .

practiti oner ,

7. Re ea rch comin g out of th e behav ioural c1ence th at is related to
vaccine he itancy or refu al that in clud e recomm end ati n relevant
to primary care practi ce.
iti on to th e HP V or

Exclusion
Criteria

2. Studi es th at exa mine vaccine oppo iti on fo r reli gious rea on .
3. Opini on pieces, co mmentari e , and editoria l that di scu
phil o ophi ca l oppositi on and make reco mm end atio ns fo r practi ce.
4. Article that discu s vacc ine uptake in under-vaccinated popul ati on ,
whose caregivers are not philosophicall y oppo ed to immuni za ti on
5. Aliicles that rep01i research th at is not appli cable to prim ary care
practi ce.

This review included

urce where th e reco mmend ati ons were derived from

research applicabl e to primary care prac ti ce. Given that vaccine hesitancy i an is ue
fa cing many first-world nation according to Luyten et al. (20 13), re earch that e ami ne

2
r I vant a
u

inati n 1 u

f th w rid wa includ d wb er it wa deem d

in other part

ful fl r infi rming primary car pra tic m

anada.

Step 11: Preliminary S earch
nee the in lu i n a nd e

lu i n criteria had be n et ut, a c mpre ben ive

earch f pee r-r

w d literature wa initi ated by way f th e fo il win g data ba e :

PubM ed, M edlin

1 H

arch t nn -

and the

chrane

p c i fi e t id enti fy in g to pi

re la ted t evi den e-ba ed nur in g from th e

m di ca llit rature- were dev i d a l ng th e line
and

iii ka (2005) . Th e

o llaborati n databa e . Prelimin ary

f th

e propo ed by Di e n o,

uya tt,

are et ut in Table 2 w hi ch gr up th e term accordin g to th e

p pul a ti n , th e pr bl m , and th r co mm end d int rv nti n . T he earch wa c ndu ted
by combining th e D !l owing tenn in a ri u way and in eac h of th e databa e .
Ta b! 2 ear h term f or the integrative r e1•ie w
Population

par nt

Probl e m

vacc ine , pati ent compli ance, vacci na ti on, vacc in refu sa l, vacc in e
he itancy, immuni za ti on, vacci ne, vacci nati on rate

Interve ntion

edu ca ti on

afety , tru t, comm uni ca tio n, prim ary care

Th e litera ture sea rch began w ith M edline; it comb in ed th e term s " paren t " AN D
"vaccinati on" AN D " edu cati on" and thereby y ie ld ed 5 19 re ult . T his cumul a tive result
was th en combined w ith " afety" to reduce th e numb er of pro pective source to 82 .
These results were furth er limited to Eng li h langu age ariicles pu blished between 2003
and 201 4 in ord er to include onl y the m o t current info nnati o n, thus fu rth er redu c in g th
so urces und er consideration to 74 . T he titl es and abstracts of th e e 74 arti cle were
scann ed for relevance; tho se that did not m eet th e in clusion criteri a but noneth ele
provided re levant background and conte tu a l info rm a ti on wer id entifi ed fo r th e ir
supportive conte nt.

I 'PIll: Focu

d Search

n e thi

ta g wa

additi nal

hich

mpl t 42 paper

h rtli t d in luding fiv

r id ntifi d b

ar bing thr ugh the "gr y" r

inti m1all publi h d acad 1111 literatur , i.e.,
th p r-r
ar h.

ur

deri

1ew d publi ati n th at had be n id ntifi db

n

tud b

ann1 e t I. 2 11 ),

d fr m th referen
f th

a

Ii t

f

ri gin al I tr 111

und t be f parti ul ar int re t, wa

identifi d in thi wa
a h f th e e art1 cle , ha in g met th in lu i n cnt n a. wa th en r vi wed in full
d ~ r It rele anc t th e t p1 .
b au

th ey \ ere 1 1111 n p1 cc

r

co nte t

r prim a

chara teri ti c of a

are.

mmentari
th r

eight paper w r climin t d b
ampa1gn a a trategy t 111

f th

2 paper

h rtli ted, I 0 w re ex luded

rath er th an pri ma ry tudi c

mm end at1

11 t

u e

furth er

ial mark tin g

1111muni za ti n rate i n t c n id er d lea 1ble in th e
tu die we re e elud ed beca u e, alth ugh th y I

k d at th e

inc-h itant parent , th ey did 11 t id entify any trateg ie pnm ary

care prov id r mi ght u e to propel th e e parent to con ider vac inati n. Three tu die
were e clud d beca u e th e e amin ed attitude toward vacci ne th at arc not in th e
routine chedul e f immunizati n

~

r hildren. Two tudi c we re e eluded on th e ba

of th eir focu on mcrea mg acc ine uptake in p pul ati on of children wh are un d rvacc inated du e to ocio-economic fa tor .

furth r two tudie - although th ey ~ cu ed

on th e relational contex t of pati nt/prov ider interac ti on and it

[feet

n ace me

h itancy and refu al- were exc luded beca u e th ey did not pro po e pec i fi e trateg ie to
increa e immunization uptake. Finall y, a paper that had been fl agged a u ful £1 r thi
r view wa exc luded de pite being appli abl e to primary are prac ti ce
it ackn owledged ignifi ca nt hort
impli ca ti n

min g in it data-co ll ecti n pr c

~ r the reliability of th e in~ rm ati

n reported.

n the ba i th at
thu ha ing

34
ntific rig ur of th
trategie

t ut by

tudi

re i wed wa a

i ndo-Wo d, Hab r

iden e wa de elop d ~ r th purp

d by way f "critical r ading'

am ron , and

ingh (20 1 ).

table of

e f thi re iew in rd r t rate ea h tudy on a

ale of 1 7, depending on the type and tr ngth f the findin g . Finding fr m
qualitati e tudi e are ranked I w r in th hi rarchy of r
W

a r h pr po ed

d et al. (2012), where rand mi z d clini a l trial are

tandard . ' lt h uld b no t d, h w

ndo-

n id ered to be th "gold

r, tha t qualitative re

arc h i noneth ele

pr vid e in ight r Je ant to th e und er tanding of accin he itan y

lik ly to

e pec ia ll y g iven a

topi th at Ia k a ignifi ant body of lit rature fr m whi ch to draw . App ndi Apr v id
th tabl e f

idence de e l ped t a i t th e analy i a! ng the lin e of th e hi erarc hy of

vid ence a propo ed by Lo i nd -

o d e t al. (20 I ).

ln the end , e ight primary tudi e and tw rev iew s tudi e were
inclu i n in thi integrati ve review . They included o ne rev iew from the

Jec ted ·~ r
och rane

ollaboration (K aufm an eta!., 20 13 ), one y tematic review ( adaf eta!. , 20 13 ), two
randomized control tri al (H endri x,

innell, Zimet, turm , Lane, & D w n , 20 14;

ai toh

et a l. , 20 13), one qu a i-experimental , pre-te t/po t-test tudy (Va nni ce eta !. , 20 11 ), one
study using mixed m ethods and experim enta l de ign (G lan z e t al., 2013 ), one urvey
study (Kempe et a l. , 20 11 ), and three qualitative studi e (Leak,
Burge , 2006 ; M cMurray,

heater, W eighall, Nel on

hapman , Hawe, &

chweiger, & MukJ1erjee, 2004;

Opel e t a !. , 20 13) . The Cochrane review and th e sy temati c review, were included on the
basis of their direct re levance to th e research qu es tion and th e expec tation th at the
conclu sions therein could add strength to the finding revealed by the primary tudi e .

Step IV: A nalysis and R ep orting
The e ight primary studie and two review tudi e were anal yzed in detail and
pec ific th emes or issues were id entifi ed . Specifically , eac h paper wa e amined for

5
pra ti

r

mm ndati n that

uld b u eful t P P in th pr c

afdy

of addre ing the

recommendation were analyz d n

tb ba i

fth ir

nt nt and gr up d into th m

commun1 ati n int rv nti n a an o

r ateg n

.

ll 10

ur e identified

rarching th em ; tbi wa brok n d wn int thre

ub -th me : th e c nt nt f what wa t be communi at d, th e timing of th
upp rt the utility of a vaccine

communi ati n and th lack of

mmunica ti on interv nti n. ach f th e e ub -theme
con id r d to be rele ant t primary car practi
uptake in caregi er who he itate t va

ncompa

where the g a! i to increa e vaccine

inate th ir children n a philo

The following e ti on ofthi paper wi ll identify the finding
arti cle orga ni zed a

r commendati n

phical ba i .

f th e 10 r view

rding to their r pecti e theme , r late th ese finding t th e

fuzzy-trace th e ry, and di cu

rcc mm nd ati n

~

r primary care practice, educa tion,

andre ea rch.
tudi

th at did n t meet the inclu i n cri teri a t r thi s integrative review ca n till

offer in ight in their own right, or support the finding

f the directly relevant studies

elected for thi s review . imilar themes emerge from the excluded tudie , de pite th eir
examination of vacc ine refu a! or hesitancy in different contexts . Both combine to help
understand and substantiate the coll ecti ve finding of a limited body of re ea rch .
Informati on from four exc luded articles (Gazmararian et al. , 20 I 0; Luyten et al. , 20 13 ;
Reich, 20 14; Shelby & m t 201 3) will be briefly discus ed in light of the finding of the
included studi e in th e following secti on.

36
HAPTER 3
Findin g

hi integrati e r
i t t h lp

va

p

uptak .

111

lit ratur

i w addr

mmunica t

the que ti n f what

itant famili e in rei r to increa e

a m

total of 10 re i w artie!

ear h. a h tudy id ntifi ed

iden e-ba eel trateg ie

w r ch en on the ba i

mmuni cati n a a

fa c mpr hen i e

mm nth me

uld tackl the impotiant i ue of va

wa in whi h health care pr

a th

nly

ine he itancy.

H w v r, each ariicle appr ac h d thi th m fr m a different angle. ome findin gs
focu eel on th c nt nt of the c mmuni ca ti on ab ut accin e wh re other focu eel n th e
timin g f th

mmuni cati on and it

a cinati n.

ppendi

t n h w p opl e make d ci i n ab ut

, eli pl ay a fi gur of the thematic analy i ~ unci whil e
f the review literature. The findin g will be eli cus eel in th e

examining the findin g
conte t offu zzy- tra

e f~

theory; th y wi ll be c mpar cl with th o

supporti ve but e clucl cl r
impact on primary care

propo eel by the

iew literature, and they will be evaluated fir th eir potenti al
P practice.

Vaccine Communication Content

The introduction and background in Chapter 1 of thi pap r eli cu s th e
communication chall enge faced by hea lthcare prov id ers in the wake of vacc ine he itancy.
To reiterate, healthcare prov iders are constantly chall enged to communi cate
vaccine-preventable eli sea e risk and to counter the arguments of anti -vaccine web ite
and main tream media . Health communica ti on itself has changed a caregivers tum to
infonnation now ava il able on the Intem et in ord er to an wer hea lth-related que ti on where they are inundated by contradictory message r garcling the afi ty of vaccine and
the risk of contrac ting and spreadin g a communi cabl e eli ea e. Research ha re ponded to

37
th

chall ng

deli

r the

hild-

, l oking at way in whi h healthcare pr

id r can b

t c n truct and

ntent of th ir ac in -r Iat d c mmunicati n.

nlred ommuni ation
H ndri e t al. (20 14) onduct d an nline sur ey f 02 par nt in the

e amin the ffi cti

n

d

inati n. hi

i ion about va

f mpha izin g th e b nefi t t
tudy intend d t

iety when it

hall ng pn r re

to

m e t m aking

arch which

indicated that em pha izing th

ietal benefit of accinati n in adult led t increa ed

va cine uptak . H ndri et al. I

k d at whether tb

arne re ult would be true when it

cam to accin atin g children, u ing th mea Je , murnp , rubella (MM ) vacci na ti n da ta,
i.e., wh th er information emp ha izing th ben fits of thi vacci ne to c hildren and/or to
ociety wo uld increa
ent r fi r Di

a e

acci ne int nti on . R e ult were compared with th e tandardized
ntr 1( D ) Vaccine lnf01ma ti on tatemen t (V I ).

part of a national onlin e urvey, four different onlin e vacci ne information
tatement were ent ut t rand mly elected parent with infant le

than one year of

age, to be followed with th e urvey que tionnaire . ach hou ehold received o ne VJ and
the survey . The fir t VI

imply et out the sta nd ard

D

information regarding the

MMR vacc ine without any reference to benefit , eit her to children or society in genera l.
The e hou seho lds we re identified a the control grou p. T he eco nd V I empha ized the
benefi t of the MMR vaccine to the individual child; the third emphasized the benefit of
the vaccine to society; and th e fourth em phasized the benefit to both ociety and th e
child.
The online survey that accompanied each statement asked th e parti cipa nt to
indicate on th e b asis of the VIS , th e likelihood of their vacc inating th ir child with the
MMR vaccine- on a cale of zero to 100, with zero meaning "e trem e ly unlikely to
vaccin ate" and 100 be in g "extremely likely." The participants were in tru cted to an wer

38
th qu

ti n

nly aft r r ading th

I and ke ping th ir infant in mind . They w r al

a k d ab ut d c1 1on th y may ha

made in th pa t with r 1 ct t vaccinating th ir

oth r hildr n . They w ere not a k d t r p 1i n th

ffe t th a t the int rmati n pro vid d

oci -d m graphi da ta wa al
Th m ajori ty f th
r la ti

e who re p nd d were

ly hi gh h u eh ld in

auca ian m oth er , we ll -edu ca t d, and w ith a

me. Thi poi nt i pe1iin nt gi

n th at thi dem ographi ha

a l o b en h wn t b m r lik 1 t ha e un a ci na t d chi ldr n nth ba i
o ppo iti n r

ted in phil

th at, w here th e dir

colle ted.

f

phi cal be li [ ( m ith e t al. , 2004 ). Hendri e t a!. (2004) fo und

t b n fi t f M

R a ci nati n t th ind ivi du al child wa

emph a ized- or wh re th di rect benefi t to b th th c hild and

cie ty wa emph a iz d-

the re ult ind icat d a gr ater int ntio n to accinate. imp ly emph a iz ing th e benefit
o iety did n t r

ult in a hi g her inci d nee of a parenta l intenti on to vaccin ate .

T here were everal lim itatio n to thi
canva

tu dy . Fir t, th e am p le of careg iver

ed wa re la tively bom ogenou , i.e., n ot rep re

ntati ve at th e

cio-dem graphi c

level. Hendri et al. (2004) acknow ledged that havin g a more ocio-demographi ca ll y
diverse ample mi ght have produced different intenti on-respon e patte rn s fo r each of the
four statem ents. A dditi onally , the difference in the vacc in e intentio n leve l between the
four different VIS group s were mo des t. T he auth or noted th at th ey did not ee a
sub tantial increase in MMR vaccine intention whe n ocieta l benefits were tre ed in
the ab ence of any direct benefi t to th e ch ild . The author , however, propo e th at even
these mo dest di fferences could add up to a s ignifi cant diffe rence w hen takin g into
account publi c hea lth con iderati on wi th respect to herd immunity ra te . Wh e th er or not
this degree of difference would vi ibl e at the indi vidua l leve l w ithin a primary care
practi ce rem ains to be een.

39
Th

th r limitati n t n t with re p

(2004) i th

do

n t

for MMR-

valuati n fva

nclu i

111

t t th e tudy

ndu t d by H endri

t al.

intention a the outc me variabl . The data ollect d

ly predi t that parent mad

n t ha ve th eir infant va cina ted

it imply id entifi e th eir intenti n t

ac ina t at th tim tb y campi ted th e

ur
The H endri

t al. 20 14) tudy i non th e! s re i va nt t pnm ary car and nur e

pra titi n er prac ti ce gi en that the findin g d indi ate tha t c mmunica ti on betw en
h a lth ar pro ici er and ca reg i e r mu t centre n the d irec t bene fit
th e individu al child , rath er th a n tre
re

arch th at look at th

ub tanti ate the finding

f vacc in a ti n to

th e benefit to o ie ty a a wh I

ci 1 gica l

1ewp int of va c in he i tant and r
f the H endri et a l. (20 14) study . 8 hav i raJ

to
ci I g i t

J nnifer Reich (20 14) argue th a t m tb er who r fu e tate-mand ated vacc in e for th e ir
c hildren foc u

!ely n th eir own hildren ' hea lth and rejec t th e arg um ent th at th eir

cho ice not to vacc in ate th eir c hild und erm in e com m unity hea lth . Reich ' findin g a l o
indi cate that th e benefit of vaccinatio n would be t be framed in term of ind ivi dua l
benefit in the hop e of increa in g vacc in intenti on .
Fuzzy-trace th eo ry provid e an additi onal per pecti ve on th e findin g th a t
caregivers w ill give priority to the ir own children ' hea lth over th at of ociety at large .
The retrieval of valu es and principles from one' background play an imp ortant ro le in
formin g the gist understanding upon whi ch caregivers ba e th eir vaccin e dec ision-m akin g .
Gi ven that gist representations are subjecti ve interpretati ons, the socia l va lu e of th e
caregivers will affect their gist fo rmati on a nd th eir sub equent dec ision-m aking. From th e
persp ective of the parent who sees onl y the hea lth of the ir child as central- and give no
weight to the wid er community- it is unlikely that a public health initi ati ve, w hi ch give
precedence to th e hea lth of the "herd ", w ill have the de ired effect on the

parent .

40
tr

ing the alue fa publi h alth initiati

car gi er with indi iduali ti

o ial alu

thi findin g th y may non thele

[!

.

will fail t impart m aning t a

en if h alth are pr vid r wer a war of

1 c mpell d t impati their und er tanding of the

e tent to whi h immunizati n pr teet the uln rabl member

f an entir c mmunity in

the h p of

that th eir indi idual choice have a wid e pread impac t.

H althcar pr

gni ze thee tent t whi h, by takin g thi approach, their

tat ment may not be ongru nt with the p iti n [ th pati ent they are w rkin g with .
Re ear h fr m b th medi cin and th e b hav i ural cience
th at, where th re i he itation or pp
gi e cr dence to the
review, n the ba i

ietal ben fit

upp rt th finding

iti n t vacc in ati on, parent are rarely inclined t
f vaccination. Two tudi e exclud d from th i

f th e clu i n criteri a d cri bed above, d

findin g . azmarari an et al. (20 10) e ami ned matern al attitude

ub tanti ate th ese
urround ing the

influenza vacc inatio n, which i n t a r utin childh od immun izati n. Luyten et al.
(201 3) did n t focu e clu ively on caregiver vacc ine he itancy but did look at th e
attitude of vaccine keptic who e pr

ed doubt abo ut all vacc ines.

Gazmararian et al. (2 0 10) exam in d the level of knowledge and th e attitude of a
focus-group of mother with re pect to influenza vaccin ation. Wh en inve tigator
que tioned the mothers about the valu e of pro tectin g the wi der community they noted that
moth ers, both pro-vaccine and vaccine-he itant, viewed the pro tecti on of the indi vidual
child a the mo t compelling reason fo r vaccinati on; th ey fo und th at th e idea of
vaccination to protect other from influenza did not resonate wi th mo t of the parti cipant
in the study. Interestin gly, both the studie undertaken by Hendri x et al. (201 4) and
Gazmarari an et al. (20 10) included participant with a vari ety of opinion abou t
vaccination- whi ch sugges t that provider should be framing all their vaccine-r lated

41
con er ati n with areg1 r , r gardl

fwh ther the

areg1 er are pp

d r not

with an mpha i on th benefit f accinati n for the indi idual.
L

king at vac ine he itan y fr m an th r per p cti

ut t e amin th d finin g chara teri ti c

, uyt n tal. (201 )

f acc ine kepti

by fo cu ing n th ir ba 1c
h

p ych I gi al di p iti n rath r than th eir und rlying m tive
wh th r a cine kepti
ther

outl ok toward

' attitude t ward

iety in general.

th p ych I gica l di po ition of accine k ptic made them le
in th eir

cia! relati n .

mmuni ty a

ltern ati ely, tud y pa rt ic ipant wh

qual had am rep

itiv di p iti n t ward

re ar her co nclud d th at

c ia! marketing f accin ati on-

ben fit to th c mmuni ty-

d

urvey e amined
iat d with th eir ba i

a cinati on w rea

mm uni ty m m be r or

t

he tudy found th at
likely t va lu

qu ali ty

aw member of th eir
acc inati on. The
whi ch foc u e on the

not ma tch we ll t th e prevai ling viewpoi nt of vaccin e

keptic . Thi fi ndin g confi1m tho e of Hendrix et al. (20 14 ); bo th indica te th at vaccine
comm unica ti on tend to be m re ucce fu l when centred ar und th e benefi t t th e
individual child .
Presumptive versus Participatory Comm unication
Opel et al. (2 013 ) examined th e influence of pecifi c provider communi cati on
practices on parent ' re i tance to vacc ine recommend ati on by way of a cro -sectio nal
observati onal study. A year prior to thi s tudy, thi meth od fo r observational re earch was
pilot-te ted with a smaller number of parent and was bown to provide va luable in ight
into communi cati on practices that re pond to parental vacc ine be itati on (Opel et al. ,
201 2) . The pilot proj ect found th at providers who u ed a presumpti ve approach to

initia tin g vacc ine recommendations, e.g., " So it' time to have ome immunizati ons
tod ay," versu a parti cipatory approach, e.g., "Are we go ing to go ahead with
immunizati ons today?" were more effec ti ve in increa ing vacc in e uptake in hes itant

42

par nt . Th purp

f the econd tudy wa t confirm th

mmunicati n pra ti e tha t pr

id r u

findin g and iden tify th er

d that c uld be h wn to either he ight n r

all viate parenta l re i tance to vac ina ti n.
The re

id

tap d pr v id r-pati ent conv r a ti n during health

up rvi i n i it at p diatric primary care c lini c in ea ttl e, W a hin gt n . T he
parti ip ant wer 1 y ar
ag

f age or ld r

of one m nth and 1 mo nth .

poke

ng li h, and had a hild b tween th

11 parii ipan t were a ttending pr im ary care prac ti c

a pp intment for hea lth up rv i i n i it w ith ith er a pedia tri cian or a pedi a tri c nur e
practitioner. T h pa rti cipant w re r

r-ui ted by re

r

rtain d to e tab li h th e ir e ligibil ity . Pa rent w h

m and th eir d emograph ic wa a

m t th inc lu io n crit ri a were furth er
accine u rvey (P

a rch a

i tant in the c linic waitin g

reened u ing a P arent A ttitu d

ab ut

hildh oo d

V) a a way f ident ifying vacc in e- he ita nt pa re nt . T he tand ard

PA V wa a ltered fo r the purpo e of thi

tu dy t include chil dh

d hea lth topi cs uch

a v itam in D, brea tfeedi ng, and Jeep pattern s in order th at pa rents not be a lerted to th e
vacc in -centred focu of the tud y.
Vacc in e-hes itant pare nt were over-sam pled in th e Opel et a!. tu dy (20 13) in
order to provide releva nt in ights into th e ir behav iour. Both e li gib le provi der and
partic ip ants were to ld th at th e re earch intended to exam in e paren t-provider
communication patterns during hea lth up ervi ion vi its, w ith attenti on to the way in
which general hea lth topi c were approached in thi

etting. T he topic of vacc in ati on wa

not fo regrounded in order to redu ce the risk of the " H awthom e effect" (or "ob erver
effect")- the we ll -known effect that ob erva ti on ha on a ltering the behav iour of th e
observed- in this ca e, the effect of knowi ng in advance tha t th e focu of the tu dy wa
vaccin ati on communication .

43
T he
h alth care pr
vid

pel t a l. tudy (201 ) nc mpa

d 111

ac in ation di

id r w rkin g in nin dif-D r nt practice . Th

u i n from 16

interchange w re

tap d during hea lth up rv1 1 n i it . Fifty p rcent f th e parti cipa nt had air ady

been id ntifi d a

ac ine-h

vac 111 -r la t d di

u

itant n th ba i of th e P

ion wer full y tran

rib d .

V

re nin g too l.

nly the

ualita ti e da ta fr m th vid eo taped

wa cod d through th e u e
h a lth care pro id r com munication prac ti ce , a w 11 a the pa ttern
th

pra ti ce . Bo th th

m ade awa re f th h

nv r ati nal ana l

itancy tatu

f parental r

p

in e tigator were purpose ly n t

ft h parent in rd er to av id influ en ing th eir

ana ly i . T h fi na l c d ing c hem inc lu d d 15 acci ne comm un ica ti n prac tice .
uantitative da ta g nerated by th e
P ea r on
h

x~

pe l et a l. (20 13) urvey wa ana lyzed u lll g

r Fi he r' e ac t te t t c mpare thi data to c haracteri ti c am o ng vacc in e-

ita nt and non-vac in -he itant parent reco rded in th e heal th up erv i ion vi its. T hese

ana ly ti c te t were al o u ed to compare hea lth care provi der ' comm un icati o n prac ti ces
w ith vaccin e- he ita nt parent and non-vacci ne-he itant pa rent , a we ll a d i cu si n
w ith first-tim e vaccinatin g parent and non-fi rst-tim e vacc in atin g parent . Quantitative
data ana lys i wa al o und etiaken to ex pl ore th e bivar ia te a oc iati on b tween th e
outco me of parent re istance to th e provi der 's reco mmendati o n, and the provider
communica ti on practi ces of initiating and pur uin g furth er di cus io n related to vacci ne
hesi tancy.
T he Opel et a!. (201 3) findin gs provi de som e thou ght-provoking ins ight into
vaccine communicati on practice . This research took a m ulti -faceted appr ac h to look at
th e i ue of communication prac ti ces and vaccine hes itancy and th ereby provid ed insights
at three levels: fir t, genera l communi ca ti on prac ti ces n th e ba is of par ental he itan y
status; eco nd , parenta l re pon e to a pre umpti ve ty le: " o it 's tim e to have orne

44
immunizati n t da

' in antra t to the pa1ii ipatory ty le f " Are w e goin g t g ahead

with immuni zati n t day ."; and third pr

id r re p n e to parental re i tan e. Th

tudy ~ und th at 62% f pr

pli itly pur ue parent

a cin

id er did not

· 55% di cu ed th ra tionale :[! r va

in ati n · and 55% di cu

f the reco mm end d a cin ati on . With re pec t t

id
of th pr

ider (n = 69) u

ln re p n

, 74%

n the t pic f
d th p tenti al

mmuni ca ti n ty l

74%

d a presumptive tatemenl t intr du ce th e vaccina ti n pl an .

f par nt (n = 1) a cepted the provid er' pre umpti ve ta tement on

vacc ine inte nti n , and 26 % (n = 1 ) re i t d . Jn co ntra t, w here 26% f pro ide r

(n = 24) u ed a participato1y statemen t, 4% (n = 1) of parent accepted a vaccin ati n pl an ,
I % (n = 3) pr vi d d th ir own alternati e plan for a

in ati n, and 3% (n = 20)

how d re i tance to a ac ina tion p lan .
In ca es w h re pr vid r m et w ith re i tance to th eir vaccin e reco mm end ati on
50% (n = 19) of th e pr
(n =

ider co ntinued to pur ue th eir vacc in ati n discu

) offered a mitiga ted

io n, 2 1%

r altered vacc in ati n plan ( uch a pur uin g fewe r vacc in e ),

and 29% (n = 11 ) acce pted parenta l re i tance with out further pursuit. Of th e provider
who co ntinu ed to pur ue their initi a l vaccine recom menda ti on , 50% (n = 19) were
characterized in the fo ll ow in g way: 47% of parents (n = 9) accepted a vacc in a ti on p lan
after the provider continu ed to pursue hi s or her recomm endati on, and 53% (n = I 0)
continu ed to re ist the provider. Upon m eeting furth er resis tance, 40% (n = 4) of
providers offered a miti gated vacc ine pl an, 30 % (n = 3) accepted the parent s re istance,
and 30% (n = 3) continu ed wi th th e pursuit of their recommend ati on .
One of th e strengths of th e Opel et a l. (2 0 13) study is th at re earchers were abl e to
observe first-hand the way in whi ch prov iders communi ca te w ith parent about
vaccin ation , in co ntra t to rely ing on eco nd-hand urvey report of accounts given by
parent or provide rs. With thi s approac h, there i less room for a ubjective int rpr tation

45
f th

p trum f r p n

and th

bj cti

"rea l w rid" ob ervati n i :D r gr unded,

giving a b tt r under tanding fwhat a tu ally tak
ac rdingl . Th re arch r
the ga p in

iden e that addr

mer a ing childh
11

aw tr m nd u
effecti

place, and h w par nt r p nd

alue in thi appr a h a a way t addre

pr vider c mmuni ca ti on behaviour m

d vaccine uptake ( p 1 t at. , 20 I ).
f th e

f the wea kne

the participant p pul ati 11 . M

pel t al. tu dy (20 I ) i th h m genou nature of

t f the partici pating parent - both vaccin -h i tant

parent and non- a i11e-he itant par nt

auca ian, 0 yea rs f age or old er, and

had a hou ehold in m up ward

mg am r di

f 75 ,000 .

c uld well have re ea led that participant

r e popul ati on ampl e

f differ nt age , ethni ci tie , r

.

.

Clo-econom 1c

bac kground re p nd differentl y to pre ump ti e or pa rtic ipat ry c nver ati on tyle .
ln additi n, ca ution need to be e erci ed in apply in g the e res ult to other
primary care prac ti ce . ir t, pre um ptive commu ni ca tio n, or th e continued pur uit of
vaccine recommenda tion in the face re i tance ri k offendin g

me caregiver . lt i a

ty le that may be interpreted a authori ta rian, and rep re ent a threat to th e ri ght of a
parent to manage th health of a child . Given the way in which hea lthcare prov ider are
already depicted in anti-vaccine medi a representati on , th i approach may co nfirm that
parental rights are not being re pected.
Fuzzy-trace theory ugges t that caregiver , face d with a pre umptive approac h
where they have already fanned a gist representatio n of hea lth care provider - as
controlling or presumptive on the topic of vacci nes- are Jess likely respond well to thi
approac h. On the other hand , caregivers who have yet to fo rm a trong gi t repre entation
of vaccination may interpret the pres umpti ve approach a an indi ca ti on th at goin g ahead
with vaccination is the socially-acceptable norm , and may therefore be more receptive .

46
It i imp rtant t n t that the
lini

inati n erv1 c 1n itu . ~

that d n t ffer a

n if a 1 r

initi ti n ty le t pur ue a ac 111 mandate, and th parent
f a

ider u e a presumpti

entually d cide in fav ur

in g th clini and arranging an app intment with

inati n, in th tim

much time, all wing th em t r nege n their deci i n.

publi c health ma g1 e par nt
Th d

ful in primary ar

trat g1 may n t be u

n t aba nd n a acc in ati n pr gram ma th en be difficult[! r parent to admit
ub equ nt " e ll -bab "app intment with th ei r pr

in the
f urrent a

1n

The findin g

ider wh n th e i uc

tatu an e .
f th e

pel et a!. (20 I

tud were n t repli ated in th e b dy f

literatur re iewed ~ r thi pr jc t. Thi i not t
trategie are n t rele ant to
Ia k f th er re ea r h t

ay th at th e re ult and rec mm end d

P practice. ll we er [! r th e purp

upp rt th

e f thi pr jcct, th e

e finding make th em difficult t Inc rp rate into a

finn reco mm end ati n [! r pra tice .
arrative-Ba ed Vaccine

ommunication

The tronge t finding th at emerged from thi literature rc iew with re pcct to
vacci ne communica ti on co ntent i th at whi ch e pou e a depa1iure from evidence-ba ed
di cu ion and reco mmend in tead an engag in g, more co ntex tu ali zed [! 1111 of
communica ti on. Three tudi

in whi ch thi th eme i foregrounded u d the [! llowing

term to characterize thi form of communi cation : experience, c nte t, narra6ve, per onal,
and torie .
In a tudy undertaken by McMurray et al. (2004), qualitati ve semi - tructured
interviews were conducted wi th 69 et of Briti sh parent who had pre- chool -aged
children. The parti cipant were recruited thr ugh five general practi ce clini

, and the

were purpo ively ampled t allow for di ve r ity in family ize, ge graphi c I ca ti on, and
eco nomi c background . The hea lthcare practi ce in v lved in th e tudy ent lett r inviting

47
all par nt

f hiJdr n b m within n

pa1iicipat in th

a ked t de

nding nth

tud . Pra titi ner fr m th fi ve general prac tice linic w r

ribe th pr ce

by

hi h a cme wer admini ter d within each

practi ce and the e re ult w re publi h d a a
om r any in

151 f March 1 98 , to

tudy. Parent w r pro ided with c nta t de tail in th event th at th y

agr ed t parti cip a te in th
al

ar

para te pap r. T hi

tudy did n t appear to

nti e [! r palii i pati n .

The purp

e of th

cMunay t al. (2 004) r earch wa t e amine p arenta l

account of dec i i n -making pr ce e in light of th M M R a

in e c ntr ver y in o rd er

to id nti fy whi ch fact r influ enced va c in uptak and w hat th e natu re of edu ca ti onal
n ed might be.

n add iti nal

ncem th at th e tu dy hoped t addre

wa tha t fa I w

perc ntage of uptake w hen it came to pa r nt decidin g to c nt inu with th e requi ite
econd MMR do e . M M urray e t a!. took th view th at th e ro le of th e primary ca re
practiti oner is k y to effect i ely in[! nni ng parent ab ut vaccination , deci i n-m akin g
about hea lth interventi on , a nd ma nagin g ri k .
Interv iew were held in th e homes of the pariic ip ant and were co nduc ted with
non-clinical re earch team mem ber in th e hope th at thi s wo uld avoid th e possibi li ty of
elicitin g socially des irab le re pon e . The content of the interview wa centred on
expl oring the experience and edu cati onal need of parents when it cam e to receivi ng
informatio n and upport in th e decision-m aking proce

pri or to th e adm ini stra ti on of th e

econd do e of the M M R vacc ine. The in terv iews were sem i- tm ctured to a ll ow th e
conversation to fl ow and new issue to be introdu ced. Pre- tudy piloting and continu ou
transcript comparison were u ed to help maintain equivalence acros the ampl e when it
cam e to the coverage of subject topics and the approach to qu e tion . Th e full tran c ript
of th e interview were analyzed u in g a "fram ework" approach: am pi es of th e tran cript
were rev iewed to id entify th eme for data codin g; code were defin ed and va lidated by

48
way f di cu i n b tw
deviant a

n t am memb r ·

wer e id ntifi d in ord r to con

rarching them e w ere
th e findin g

tabli hed ; and

f th re ear h in a

m anin g:ful w ay .
The findin g put[! rward by M cMurray et a l. (2004) c nfirm ed previou research ,
whi h al

indi ca t d th at P P r pr

immuniza ti on. How

nt an imp rtant ource f inform ation about

er, th e prim ary findin g by M cMurray et a l. wa th at m edi a!,

ci nc -ba ed infonn ati on ab ut vaccinati n
ab out th ri k and benefit

f acc in

a ~ ty did n

t incr a e parent under tandin g

, n r did thi inform ati n increa e uptake. Thi

tudy al o emph a ize th at any informati n pr
pre-e i tinge perien e and und er tanding

ided mu t be integrated int th e
f th e parent . Furth r, that th e infonn ati on

c mmuni ca t d m u t take int ace unt what McMurray et a l. de crib e a " tang ible fac t ,"
thee perie nce and b erva ti on of parent in th eir wn

mmunity. They n te th at th e

vaccinati on me sage be " pre ented in uch a way a to inform and transfo nn , x peri enti al
info rm ati on parent bring to the con ultati on'' (p. 522) . M cMurray et al. empha ize th at
healthcare p rac titi oner

hould re lay medi ca l info rm ati on w ith th e help of " vi ua l imagery

and ca e tudi es to provide vicarious experi ence of th e impac t of large ly fo rgo tten

di eases" (p. 525), in stead of impl y relay in g stati ti c and fac t .
Kemp e et al. (20 11 ) looked at th e concem of parents w ith re pec t to th e vacci ne
chedules. They u rveyed Am eri can health care practiti oner wi th a view to
understandin g the " prevalence of parental reque t to devia te from tandardized vacc in e
sch edules .. .the respo nse to th ese requ e ts .. .and attitude about th e burden and ucces of
vaccine commun ications with parents" (p . 548). K em pe et a l. surveyed what they
described a nationally representati ve ampl e of pedi atri cian and famil y phy ician - by
way of the mail or th e lntem et. A total of 696 practiti oners parti c ipated in th e urvey: 366

49

pediatri ian

and

0 famil y phy i Ian . All f the participant pr

t childr n under the ag

phy ician re pon e to th e qu
. H alth

in[! rrna ti o n

111

it:u

tal. (20 11) d cument, among oth r thin

,

f tw .

In th cour e f their urvey K mp

pra ti c

ided va cme

ti n ab ut tb

anada (2000) d fin

ri k

nc rning thee i te nce natur

nvir nmental ri k . '(p . 24 . Phy ician

fD

ti ve n

f ri k -communica ti n

mmuni a ti n a "any e chan ge f
fom1 , ev rity r ace ptability

f hea lth r

urv y d repOiied th a t th e m o t uc e fl.!! way

t c n ince acc m - k pti ca l par nt wa by u ing a per onal mes age, for in tance,
in cludin g a ta tem nt that detai led th e phy i ian '

pen en e with vaccin a tin g hi

r her

own hildre n r r a uring th par nt th at th e ph y icia n w uld accinate hi s or h r ow n
childr n .
cco rding t K m pe et a!. (20 11 ), th e ne t m
th at phy ic ian re poried wa to con

t effl c ti v

c mmuni cati on prac ti c

y th eir per onal experi ence w ith vacci ne a fety as it

wa ex peri enced by their pat ient . B th of th e e trategi

a re een to be m ore effecti ve in

conveying inform ati on th at wi ll influence deci ion in fav ur of vacc ine uptake. In thi
way they exceed the effectivene

of oth er co mmuni cati on prac ti ce trateg ie to prom ote

herd immuni ty, protec t vuln erabl e memb ers of th e communi ty , and prov id e da ta about th e
likelihood of adverse effects. K emp e et al. co nclud ed th at compre he nsive and innovati ve
approaches to risk/benefit communi ca ti on are needed in the practi ce sett ing. M ore
pecifi call y, th ey conclud ed that perso na lized m es age whi ch denote an exp rience th at
is tangible and compe lling to both the healthcare provider and pati ent appear to in crea e
the chances for vaccin e uptake in parents that are he itant or re i tant to immuni z in g th rr
children . T hese co nclusions are s imilar to tho e pre en ted by McMurray e t al. (2004 ).
L ea k ,

hapman, H awe, and Burge

(2 006) attempted to identify th e fac to r that

kept parents sure of their own dec i ion to vacc in ate th eir c hildre n in the fa e of

50
wide pr ad anti-vaccinati n me age in th e m dia . By recruiting

u tralian m th r and

gr uping th minto i ~ u gr up , th re earch r proc eded to e plore how th

e

mother r ponded t c mpetin g m dia me age ab ut vac ine afety in th fac e f what
th y de

rib ed a th " trikin g

Th purp

e f thi

tudy wa to det rmi11 e wh th er n w way

vaccinati n might b 11
~

phi ticati n fth 'anti ' vaccination ca e" (p. 72 8).
f " marketing"

ary in r p 11 e to th e anti - acc in a ti n di

ur e . ac h of th e

u gr up in lud ed betw en D ur and eight mother , all with infant children .

A c rdin g to th author , th e parti ci pant were re ruited by appr aching mother in the
'wai ting room
middle cia

f we ll -chi ld c lini c

area acr

in~ ur dem

metr p litan

yd n y ,

g raphi all y vari ed but predomin antly
u tralia" (p . 72 9) . Mothers who were

ehem entl y ppo ed to immunization w re e e lud ed from th e tudy , in pa1i t avoid
group co nfli c t but a!
oppo

becau e th que ti n being a ked would not appl y to tho e already

d to vaccinatio n .
Demographi c informa ti on wa obtained ahead of tim e by way of a que ti nna1r

compl eted by each of the mother before the e sion commenced (i ncludin g the age of th e
children and their and immunization tatu ). T he mothers in eac h of the focu group
were then provided wi th a li st of i1nmunization-related qu es ti ons to prompt open
di scu

ion am ongst the participants. They were encouraged to hare their pontaneous

thoughts about chi ldhoo d immunization and to identify what they found reassuring and
what concerned them most about immunizati on . Following thi s, all the group were
shown two v ideo "prompt "with typi cal example of vacci ne media coverage. The fir t
showed negative media coverage, including an excerp t from a docum entaty re la tin g to
alleged ly vacc ine- injured children; the second showed po iti e coverage and included a
segm ent where a phy ician di scu ed the dangers of non-vacci na tion , and footage
show in g c hildren ill with pertu i and meas les. Two of th e si focus group viewed an

51
c ntaining fl

additi nal id
I bby

h wing fl otage f fi

tage that had be n ircul a ted by Au tralia ' anti-vaccin
m edical d

t r pre nting their argument again t

immunizati n .
.. ach group wa a k d t di cu
r

th eir rea ti on t ea h vid

archer/m derator a ign d t th e ir group . T h

tran crib d .

ne to two da

pr mpt with the

n w re ta pe-re

rd ed and

afte r th g r up mee ting th primary re earcher c ntac ted

each m ther for furth er di cu

ion a nd d bri fi ng, durin g whi ch the re earch r to k

e ten ive note but did not m ake an audi o rec rding . D ata fro m th e fo u group were
tran c ribed a nd coded w ith

ftwa re de ig ned t d qu alitati ve analy i . Them ati c

analy i wa u ed to ident ify emerging th em

, whi ch were then organi zed into a

coh rent hic rar hica l chem fo r ana lys i by th e re arc her .
Lea k et a!. (2006) emp ha ize th a t trus t in th e fa mil y do t r i integral to th e
feelin g of comfo rt e pre ed by the mo th er in thi s tud y w hen it came to mak in g
vac ina tio n deci io n . Th i

tu dy bowed th at parti cipa nt va lu ed doct r who took th e

time to expl ai n proced ure and discu

ri k ; partici pant fe lt Je

comfi rtab le wi th

practiti oners who evaded vaccine d i cu ss ions. Leask et a!. recommend th at cl ini ca l
prac titi oners no t re ly on fac ts alone to convi nce parents of vacc in e afety; thi i th oug ht
to be insuffic ient given th at uch a communication trategy fai l to acco unt fo r the wide r
valu es and di cour es that inform dec ision-makin g. Lea k et al. noted th at the fac t-ba ed
conte nt, commonly empl oyed to convey vaccine afety, proceed w ith th e assumpti on
th at, once people are provi ded w ith th e "facts," they wi ll not be influenced by
anti-immuni za tion rhetoric . However, Lea ket al. foun d that m other rejected antivacci ne informa tion on the ba i of the ir own logic, trust in their care provider, and th e ir
own persona l exp eri ence w ith vaccine-preventabl e di sea e .

52
a k tal. (2006) point ut th
baring of p r

alu

f per anal e p ri nee, and recount the

durin g the :b cu

n al e peri en

where "group m emb r

becam un hara teri ticall y qui t with fa ial e pre ion and xclamation refl ecting the
with whic h th y b ld tb

" (p . 7242 . Thi ob ervati n und r core th

recomm ndati n t ha e prim ary ca re practiti ner me rp ra te narra ti ve account into
the a

m c mmunica ti n proce .
T hi

tudy ucce

yed h w middl -c ia

a cin ati on appr ac h th pr c
pr paga nda .

rand m

f m aking de i ion in th e face of anti -vacc in ati n

one th ele , th ri k o f

parti c ipa ted in thi

wo men wh o upp ort

lecti n bia i hi gh g ive n th at th e m oth er wh

tud y we re recruited fro m clini c waitin g r

lec ti n proce . T hi

tudy did not in clud a foc u

m rath er th an by way of a
d c n id rati n of h w

h alth prac titi o n r influ n e the parental de i i n-m akin g pro e , a 1111
wa

in g pi ce th at

een in th e pri r tudi e relevant to thi th eme.
Eac h of the e tudi

qu e ti on th e u

of communi ca ti on stra tegie th a t rely

Iely

o n fac ts and favour the u e of nan·ati ves th at recount per a nal ex peri ence , wh eth e r it be
th e experience of the practiti oner or th e careg iver. Even th oug h each of th ese tudi e
occurred in di fferent geographica l loca ti ons, w ith different pa rticip ants, and utilize d
di fferent re earc h m eth od , there i di cem abl e upp ort for a departure from
communication th at contains evidence-based fac t

urroundin g immunizati on in favour of

narrati ve-based vacc ine communi cati on th at is hi g hly indi v idua li zed by content from the
hea lth care prov ider ' s personal and profes ional exp erie nce.
Shelby and Em t (201 3), two mothers, and fo und ers of th e pro-vaccine web ite,
M om W ho Vax , published an articl e in a peer-reviewed j ourn al w her th ey emph a ized
the importance of using na rrative and st01ytelling to counterac t the impact of th antivacc ine m ovement. Thi article was excluded from the rev iew but is no nethel

noted

53
h re b cau e it pr
t influen

ide a patient p r p cti

th d ci

n-making pr

t ryt lling c uld help health care pr
a cin -re i tant pa rent . T h y ba
toryt lling trat g i
w id

on th 1mpa t fu in g per

. Th a uth r argu th a t narrati
id er addre

the c laim

nal natTative
and

f vaccin -h

itant r

thi rec mm nd a ti n n th ir c nv icti n that

ha e a ll w d anti -vac ine group s to ga in popul arity and a

pread fo il w ing . t ry t !ling n anti-va

ine w b it - recountin exp eri enc

w ith accin -inj ured childre n- all w th fi rmati n of iti ua l co mmuni ti e of parent
wh

e nan a ti

tran fi rm into "fa t " th at dri

beli f: , w hi h in tum inti rm dec ision-

m aking about medica l i ue .
h !by and - m t (20 13) encou rage pro- acc in e ad oca tes to u e thi same
paradi gm of m aki ng per

nal tori e pub lic, and n te th at parent wa nt t hear hea lth care

provi ders re lat th ir wn e perience th rough t rytellin g in th e exam room .

Ps who

ha e previou ly worked in pu bli c hea lth a regi tered nur e where th ey adm in i tered
vacc in e to children may have th advantage of be in g ab le to c mm uni ca te a va ri ty of
experience to parent . imi larly, any primary care prov id er w ho i a parent or ha
worked abroad in countrie w ith outbreak of vacci ne-p reve ntab le commu nicab le
di ea es can tra n fo rm th eir ex peri ence in to a nan-ati ve that bel by and Em t predic t w ill
have a posi ti ve imp act on vaccine uptake in he itant parent .
Fu zzy-trace th eory supports thi s tacti c a nan-atives and tory tell ing are clo ely
ali gned w ith the m eanin g a pprehension tha t creates gis t representation and ultim a te ly
informs vaccine decision-m aking . In es ence, hea lthcare provider need to ma tch the
elaboration and personali za tion of th e stories ba red by anti -vacc in e in fo m1a tion ource
in order to provide a persuas ive m e age tha t fo rm gist repre entati o n and upp ori
dec i ion making that lea ds to in crea ed vaccine upta ke. H ea lthcare provi der m ay ne d to
con id er the pos ibility th at the ev id ence- ba ed info rmati o n that inform th eir clin ica l

54
pra ti
r

may n t tran late in t a uffici ntly

mp lling ca e to prompt aregtver to

n id r their a cin deci i n-making.
Th int nti n of thi r view i to rec n id r the pre iou em ph a i

pr vid r rel ati n hip a d t rminin g influ n
car gtv r ar

in the deci ion -making pr ce

nth pati entto whi ch

ubject. H w v r, th findin gs that fav ur th e inc rp rati on f narrati ve-

ba ed vaccin c mmuni ati n are am ng th mo t int r tin g re elati n that thi r vtew
ha unc

ered. Thi inter enti on doe

interpr ting caregiver ' fram

hall eng P P to utili z their relational kill

111

of refer nee int a nan ative that incite pertinent

under tand ing.
Vaccin e Co mmunication Timing

ignifi cant [! u

f the re earch rev iew d here ha t d with th imp rtance of

accine communi catio n tim ing. peci fi all y, when do conver ati on about immuni zation
ha e the mo t benefit when it come to increa ing vacc in up lake in infant and yo un g
children? It i im po rtant to note that the e rec mmendati on generall y identify a proactive
or "up tream" approach t counterac ting vacci ne oppo ition. The idea i to prevent
he itancy and resi tance from taki ng hold and ga ining momentum, and n t wai t until it is
e tablished and then work to counteract the he itancy by vari ou mean
Prenatal Vacc ine Com munication

Glanz et al. (20 13) investi ga ted the process whereby parent made decision about
vaccination and looked at the rol e of tru tin their relationship with their phy ician
They described their inve ti ga tion a a mixed methods study that rebed on focu groups
to guide a urvey de ign.
The parti cipants in this study included 173 parent with children under the age of
four, conducted over two years. All the parti ci pant were recruited by way of an
Ameri can group health in surance pl an on the ba i of hav ing either refu ed or delayed

55
va cinati n due t p r
int

nal non-m di al r a

enD cu group wh re they

n . The tudy gr up d the parti ipant

er a ked to c ntribut t in-group di cu i n

ab ut immunizati on. F ur D cu group were compri
and thre group w re c mpri

d f par nt who r fu ed v ccme ,

d f accine-he itant pare nt who purp

ly d Jay d th

vac inati n ch dul e for their children.
a h of th e D cu gr up meeting wer moderated and Ia ted betw

n 60- 0

minute . Th m derator a ked qu e ti n r Jating t parental va cine dec i ion-makin g
, par ntal

penence wi th th eir pediatrician , wheth er r n t they tru ted th eir

pedia tri cian ' ad ice, and th 1r

urce of acci ne informati n.

udi o rec rding were

made and tran cribed by ind p nd nt tran cripti o ni t . T h data wa analyz d by way f
a tea m-b a ed , inductive appr ach- whi h in o rp rate the principle of "ground d
th ory"- a qualitativ re ea rc h m th od that help to exp lai n real-w rld pheno mena . T he
data wa c ded and categ ri zed to reveal any uniqu e th me that aro e o ut of th e f< c u
group e

1011 .

The inf rmation that resulted from the focu gro up re earch wa th en u sed to
develop a survey to examine parent-provider tru t, vaccine deci ion-making, co nfid ence
in vaccine information, and demographics . A rough draft of the urv ey wa pilot-tested by
a mall sample of parents , and then rev i ed . This time the tudy included parent from the
group health insurance plan who had not parti cipated in th e initial focus group e sia n .
These parents were divided into three group : vacc ine acceptor , delayer , and refu er .
Surveys were mailed to a random sampl e of vaccine accep tor (n = 500), all of the
delayers (n = 227) and all the refuser (n = 127). Descripti ve tatisti c were u sed to
calcul ate all demographic info1mation obtained from the urv ey , andre pon e to the
vaccine-related survey qu es tions were co mpared across the three group s of parents u ing
chi -square tes ts and multivariable polytomou lo gi tic regre ion . Logica l regres ion

56
m d 1 w r ba d nth multi!
fthe 1 cl

1 d p nd nt ariable (vaccine a ept, d lay, orr fu e).

ed- nd d que ti n , nin wer m a ured on a Lik rt cale; fth

w r de cribed a eith r di h t m u or at gori al· fi

qu

e

i

tion mea ur don the

ikert cal w r di hot m1 z d according t th e tr ngth of agreement ( tr n g ly agree,
di agree, neutral) .
lanz t a !. (2013) [! und that parent m ade th eir vacc ine de i i n durin g
pregnan y r in th e pr ce

f de elopin g th ir birth pl an. Thi finding i

pnmary car practic , e p

ially g i en th a t th

n t delay r r fu

vacc m

tudy al o indicated th a t par nt wh go

ar twice a like ly to begin th e proce

vacc in e deci ton ea rli er than parent w ho accept acc m
prenata l educati n d
out multipl

ourc

n t gen rall y add re

f int r t t

of making th eir

dditionally, becau

infant immuni za ti on , th ese parents ought

f informati n, including web-ba ed re ource , to infonn th ei r

deci ion durin g pregnancy .
Glanz et a l. (20 13) emp ha ize that their re ult have impo11ant implications [or th e
timing of vacc in e communi cation. T hey adv ise that h althcare provider carin g for
prenatal pati ent

hould initiate vacc in e-related co nversati on often during pregnancy,

and in a balanced manner with suffi c ient inform ation on b th vacci ne benefit and ri k .
In addition Glanz et al. point out th at parent differentiate their tru tin their phy ician .
That i , mo t participants reported that th ey tru st th eir doctor for advice re latin g to infant
nutrition and development, but th at th ey did not nece saril y tru t vaccine- rela ted
information becau e they felt this information did not adequate ly addre

both ri k and

benefits.
Given that parents are very attun ed to the ba lance in vacc ine-ri k communi cation,
it is important th a t healthcare prov ider rev iew th e ri ks and benefits of vacc in ation in
re la tion to the ri k of communica bl e di ea e. Thi could be c hall engin g in ca e where

57
na l
focu their m

ag

u pe t a he itancy to va

n the b n fit

f a

inat and are con

qu ntly in lin ed t

inati on in ord er t di v rt par nt from the id a

that ac inati n c ould be h armful. In

ing, what practiti n r 1 av un aid could

prompt par nt t initi a te th e ir wn m

ti ga tion f vaccin ri k , where th e ir ability to

parate fact fr m fi cti on i c mpr m1
m e ag

n web ite , bl g , and in

d by th ma

Jve v lum e f c ntradi c t ry

cia! m dia .

F in a lly, va cine-he itant parent in th

Janz t al. (2 0 J ) tudy de

rib d the ir

va c in e deci ion-m aking a a c ntinu u ly v lv in g proce , w hi ch mean th a t, to so me
degr

, parent co n ta ntly w re ti e w ith th fl ar th a t vacc in e-pr

p tenti a l to af£ ct th ei r child , and th y wi ll re-eva lua te the ir de
concern . T hi i part icul arl y relevant t pn mary ca r ; it ch

entabl e eli ea e hav th e
i n ba d n thi
a im ilar recomm end a ti on

b y Ly r n and Leona rd (2006) to rev i it vacci ne eli cu sion reg ul arl y w ith parent rath e r
than eli mi

parent who are he itant or refu e vacc in e fro m th ei r practice, a nd th reby

hut down communi ca tion lin
lanz et a!. (20 13) acknow ledge th at a weakne

of the ir tudy de ign wa in th e

selection of a sample popul ation fro m a sin g le hea lth plan in

olorado, a cho ice th a t

could limit th e generali zabili ty of the research-findin g . H owever, they emph as ize th at
condu cting this research in a tate th at a ll ow non-m edica l, perso na l be li ef exemp tion s to
schoo l immuni za tion requ irements nonethe less prov ided an idea l envir onme nt to
over-sample vaccine-hes itant parents . The auth ors, however, did no t address a potential
limitation of the stud y and th at is th e possibili ty th at focus group el i cu

ions may have

been affected by th e bias of do m inan t and/or opini onated member - in w hich case the
more reserved m emb ers could potenti a lly hes itate to pea k out and thereby skew the data
in favo ur of the m ore ex troverted v iewpo ints.

58
Th finding

f tw additi nal re iew tudie , whi h I

k d at th p t ntial

b n fit f pre- and po tnatal du ati n, au gment th e findin g put[! rward by

lanz et al.

(20 1 ). ait h et al. (20 1 ) r ruited 119 pr gnant w m n from thr ear a in Tokyo
Japan and a ign d them t
w

ne of thre gr up : a vaccine-edu ation prenatal gr up at

k ge tation , an vaccine- du ati n p tnatal gr up at -

day aft r delivery ,

or a contr l gr up which did n t r c i e an in tru ti n. Th e immuni za ti n tatu of all
f the infant wa a

ed along with pre- and po t-inter enti n written urvey . The

intervention

n i ted f ne- n-one interac ti ve edu ca ti on with n

re earcher where t p1 c m lud d inform ati on n vacc in e type
pre entable di

a

, th e effective ne

f th e

th e concept of vaccine-

and ide effect of accine , and th e procedure ~ r

bookin g infant immuni zati n . ait h et al. (2 103) ~ und th at th at th m th er of the
intervention group had a hi gher rate of acc in uptake th an the co ntrol group . I wever,
th ey al

found th at th r wa no ignifi cant dif~ renee betwee n th e prenatal edu ca ti on

group and th e po tn atal edu ca ti on group .
Alth ough the aitoh t a!. (20 13) stud y upp o1i the conclu ions of Gl anz t al.
(20 13 )- that prenatal vaccine edu cati on could in c rea e immuniza ti on uptake- it is
important to remember that thi

tudy to ok place in Japan where oc io-c ultural influences

may pl ay a part in vaccine dec ision-makin g. aitoh et al. (2013) ex pected, from th e out et,
that perinatal i1m11unization edu cati on would pos itive ly change parental immunizati on
knowledge, attitud es, and belief . But this tudy did not refer to th e organi zed
anti-vaccine interests active in Japan , let alon e to th e extent of thi impact on pro-vaccine
messages. Nor did thi s study discuss the po t-modem cultural contex t which, in No rth
Ameri ca, seems tore ult in more young parents qu e tionin g th e auth ority of their
healthcare provid er. Therefore, the re ults of th e aitoh et a l. (2 0 1 ) study may n t be

59
r pli at din c untTi
a

with gr at r challenge wh nit come to increa ing the rat of

m uptake in he itant and r
Vannice tal. (2011) a! o

immuni za ti n du ation . ln thi
Tenn

ee and

tant caregi er .
amined the effect ofpr natal and po tnatal
tudy, the educati nal inter

alifornia and wa pr

ntion to k place at clinic m

ided t 272 mother wb had indi cated c ncem

about infant vac in ati on . P tenti al parti ipant we re elected from ne of two clinic on
th ba i of r fl rral by c linic taff, wh reup n th ey gav th ir in£ rm ed c n nt, were
tudy, a nd provided wi th a cr

nin g urvey. The parii ci pant were

cree ned b [! r band t a c rtain thei r leve l of acci ne co ncern on a sca le f n to three:
( 1) b alth advo ate , (2 fence- itter , and (3) wo rTi ed . Th participant were th en
rand mly a igned to one f fl ur gr up . The fir t wa provid d wi th vacci ne information
durin g a prenatal vi it, th e econd at a ne-week, post-partum we ll -child v i it and th e
third a t a tw -mo nth vacci nation vi sit. T he moth r in th e tw -m nth c hort were
de ignated a th e reference group on the a sumpti on that mother ty pi ca ll y fir t receive
information abou t vacci ne a t thi stage. The fourth group of mothers were provided with
vacci ne-related infmmation at all three points in tim e. The participants of each g r up wa
required to read a new-vaccine information pamphlet along wi th vacci ne infonnation
tatements from the Centers for Di ease Co ntrol and Preven ti on . Attitu de toward
vacci nation were mea ured after th e intervention a nd compa red to the fmmer leve l of
vaccine concern . This data provided the ba i for the analys i .
A po t-test was u sed to m easure individual atisfaction with vacci ne informa tion
and participants were then asked at which point in their pregnancy th ey wo uld prefer to
receive this fonn of information . Change in maternal attitud e and belief about accine
safety after receiving vaccine-related information were analyzed separately for each
group . Results from the prenatal and one-week p

tnatal group were compared to tho e

60
fth two-m
accinati n

up 111 rd er to a
arli r r

wh th er r ceiving inD rm ati n ab ut

ult d in a benefi cial chang

gr up w re m ad for th e fir t thr

mp ari

all

n within and acr

group . L ngitudinal da ta from th e :C urth

"a ll-tim e-p int " group were analyzed epara te ly . F i h r ' e act te t wer u ed t
alculate th pr p rti n f pa1i ici pant w ho r p ried p
along with pr t t and p

tt

iti ve attitud e toward va

in ation,

t re po n e wi th in th e three tr a tm nt gr up . Difference in

attitud e within the all-tim -p int grou p were ana lyzed u in g a "g neralized

tima tin g

equ ati n pop ul a ti n-averag d" m de l app lied t th e :D ur time poi nt : initi al creenmg
pre na tal, p

tn atal , and the two-mon th vaccina ti n app intm ent.

Vanni ce ta l. (20 1 J) D un d th a t there we re no ta ti tica ll y ignificant di ffe rence
Ill

a ti fac ti on le el th at c ul d be a ociated wi th the timin g of vacc in e informati n

acr

the gr u p . M th r in al l gro up were ignificantly m re li ke ly l re pond

p o itive ly to qu e tions and tat m nt tha t uppo rted the afety and imp ortance f
vaccines . Rece ivi ng the vaccine informatio n earli er did notre ult in any stati ti ca ll y
ignifi cant c hanges in a pa1i ici pant ' leve l of sa ti fac tion . However, w hen the pa rti c ipan t
were directly a ked to p rovi de a preference a to w hen th ey wo uld like to fi r t receive
vacc in e-re la ted info rmation, 95 % reported th at th ey would prefer to receive it during
pregnancy or at a well -c hild visit- before the two-m onth vaccinati on vi it.
Although Va nnice et al. (20 11 ) did not di cover a change in attitude toward
vaccines , or in ati sfacti on levels based on the timin g of th e de li very of vaccine
informati on it is worth notin g that parti cip ant pref erred to rece ive info nn ati on pri or to
scheduled vacci nati on . These results echo the fi nding of aitoh et al. (201 3), and G la nz
et a l. (2013) , but there are som e di fferences . aitoh et a l. (20 13) tested for one-o n-one
verbal communi cati on a th e m eans to in crea e vacc ine uptake, wherea Vanni ce et a l.
(20 1 J) loo ked at th e relati onship between earl y in forma ti on de li very and pa rticipant

61
r p 11
va

t

i nat

the timing of thi in-D rmati n · the latter did n t
r a tua I acc in uptak . Th latt r tudy al

amine th int ntion to

had a 1 w 1 ve l of recruitm nt

randomizati n whi ch lea e it at ri k D r elec ti n bi as.

1 ite th e differen

b tween th

e tudi e , it i n 11 th ele

tha t ea rly d livery of vaccin inf01mati n can be readil y in
pra ti c

1mp rtant to note

rp ra ted into prim ary ca re

pa tii ul arly w here provid er d n t all t mu ch tim e t their app intment . Thi

way, a pnma ry a r pr vid er
pati nt and ffi r t eli cu

uld gi e vacc in e in D rm ati on m ateri al t th ir prenatal

th c ntent at th e foll ow in g appo intment. Thi timin g w uld

b in k e pin g w ith the findin g

f

lanz et a!. (2 0 I ), whi h indi cate th at

vacc ine- he itant a nd vacc in e-re i tant parent begin their earc h "fi r immuni zati on
infi m1 ati on ea rlie r th an th

e wh ha e alrea dy in favour of vaccinati on.

To umm a ri ze, all three tudi e infi rm the th em

f arly and prenata l vacc in e

communi cati n; ac h indi ate that delay in th e de li very f vaccine inform a ti on could be
to th e detriment fvacc in e- uptake ra te , e pecia ll y in vacc in e- hes itant pa rent .
Fuzzy- trace theory enh ances the und er tandin g of this findin g, given th at th e prenata l
period for fir t-tim e parent represent a point in th eir lives w here th ey lack "meaning"
w ith re pec t to vaccinati on . These parents are characterized by a trong de ire fo r
knowl edge and are also attentive to th e experi ences of oth rs to help th em ma ke en e of
the benefit and risks of immuni za ti on . Thi proces of creating meaning fo nn s a g i t
repre entation tha t w ill ultimately infonn th eir vaccin e deci ion-making proce . G iven
that it i ea y fo r primary care practiti oner to provide vacc in ati on info rmati on earl y on, it
seem s obvious tha t this m ateri al can be readil y wo rked into prenatal cia es, as well as
midw ife and obste trician practice . Thi will en ure that, at ome po int during th e
prenatal period , moth ers are given th e opportunity to proce s thi infom1a ti on and a k
ques tion s as th ey occur alon g th e way.

62

In ufficient E vidence on Va ccine Intervention
Tw re

arch review have b

m luding a wid r data et t
chran

in~ rm th

n inc lud ed in thi literature review a a way f
rec mm ndation that thi paper wi ll provide. A

llab rati n r vi ew by K aufman t a!. (20 13) c n ider d th prop

a! that

face- to -fac in:D rmati n int rv nti n may impro v va cine uptak by enhancing parental
und r tandin g . They n te that th e bj ec tiv of th ir r v iew w a t "a

th e ffect

f

fa c to face interv nti n [! r in~ rmin g r edu catin g p arent about early hildho d
a

inati n n immuni za ti n upta ke and par ntal kn w ledge" (p. 1). They e lec t d

tudi e whi ch inc lud ed rand omized co ntro ll ed tri al (R T ) and clu ter R T de igned to
eva lu at th

f~ c t

of fac -to-face in fo rm ati n interventi n

indi vidua l parent or g r up

[ parent

pr v id ed to eith er

w hi ch were ei th er comp ared t a control gr up

or another face- to-face interventi n . T hi review in c lud d ix R T and o ne c lu ter R T.
cumul ative tota l f 2,97 parti c ipant wer repr en ted by th e even tudi e

elected

for thi rev iew . Three tudi e were und rtaken in I w- or middl e- incom e countri es, and
four w ere underta ken in hi gh-incom e co untri e . The interventi on ranged fr m in g lee sion interventions to multi - e sion interventi ons, and focu ed prim aril y on th e
und er tanding and uptake of vaccine . However, th e rev iewa l o con idered, a a
seco nd ary focu , re earch that looked at vaccine intenti on , parenta l experi ences w ith
intervention, and adverse effec ts.
This rev iew did no t report a ny conclu ive findings, no tin g th at th e evidenc wa
limited, and w here it exi ted the ev id ence was found to be of low qu ali ty . From thi , th e
rev iewers co nclud ed that face-to-face edu ca ti onal interventi ons have littl e o r no impact
on vaccine uptake or on in creasin g vaccine-related know ledge . T he re iewers
ackn owledged that th ere w as insuffic ient ev idence to properly comment n th e ec nd ary
fo cus, uch as th e co t of impl em entin g edu cati nal interve nti on . T he re iewer d ,

63
h w

er pr p

that it w uld b fea ibl t in

intet

nti n int healthcar

rp rate face-to -face accme

ncount r but, giv n th la k of e id nee in the res ar h

rev i w d th y were n t prepar d to rec mm nd u h intervention in the event that th ey
111

ur additi nal e pen e by being de li
adaf Ri hard ,

lanz

r d ut id e of g n ral hea lthcar de livery .

aim n, and

m er (2 01 ) und rt

k an e ten i e

y t m ati c rev i w f interventi on a im d a t redu c in g the rate of pa renta l va cin e refu al
and accine h

itancy . T hei r rev iew :D

u eel n re earch cone m ed direc tly w ith

eva lu atin g inten r nti on u in g qu antitati ve ut

m e mea ure

pec ifi ca ll y, par nta l

accine-refu a l be hav iour, a ttitud e toward immuni za ti n, and/ r intent t vacc in ate. Th e
r V I w 1mp

eel re tri c ti n

n th date o f pub! ica ti o n- fr m l January 19 0 t 1 July

2 0 I ; it relied n :D ur databa e , earcb trategie that m ade u e of th e c ntroll d
vocabul ary of M e di ca l ubjec t H ea ding (M e H), a nd a pre- ea rcb via
For th e purp o e of thi r view,

oogle c ho lar.

adaf et a!. (2 0 1 ) in c lud ed tudi e that D cu eel

on HPV vacc ine uptak a we ll a infant/ea rl y childh oo d vaccin es . T hirty tudi e were
e lected. O f the e 13 e amined befo re-and -after interve nti on data; three in corp orated
rand omized contro l trials (R Ts), and even did no t; ix were eva lu ati on studies ; and a
total of25 studi e were und e1iaken in the US . The 30 tudi es were ca tegori zed into three
group s: 1) " pa age of tate Jaws" in cluding tudi e w hi ch loo ked at exe mpti ons to
schoo l immuni za ti on requirement for philo ophi ca l reaso n ; 2) state- and sc hoo l-leve l
impl em entati on o f laws, inc luding tudi es w hic h looked at the procedura l compl exi ti e of
obtaining non-me di cal exempti ons in th e contex t of schoo l po licie around immun izati on
require ments; and 3) studi e that looked at parent-centred immuni za ti on info m1a tio n r
edu cati on .
Sadaf e t a l. (20 13) found th at, out of a ll the studi es th at examined th e deli very of
parent-centred edu cati ona l inform ation, th e use of m ateria l w ith bri ef umma1i

( uc h a

64
pamphl t

r br chure ) appeared to be the mo t ffecti e. Th auth r

tudie aimed at d
re

tr

the need for

ping intervention that are lik ly t influ nc p rc ption , and for

arch that examine way in which b haviour can be chang d . adaf et al.

a kn wl dge that th ir re i w wa n t comprehen i e, and that it wa limited by
arching,

con id ring only tudi e that u d quantitativ re ea rch m th ds, by n than
and by not incorporating any gr y literature.
Both th

e re earch rev iew indicate th at ev nth ugh a large body re earch wa

identifi d and e ami n d, th r i !itt! eviden e th a t can be c n id red t be f g
qu ality wh n it c m

to identifying pr ductiv

amo ng th o e w ho are vac ine-he itant, r th
Th

r v iew co nfirm there ult

d

tra tegie fo r in crea ing vaccine uptake
e w h refu e t vac ine th ir children.

f thi lite rature ea rch . A lth ough a ub ta ntial

numb er of tudi e in lud d in thi integrative rev iew w re va lu ab le in ex plainin g th e
i ue of philo op hi cal oppo ition , and offered u

ful advice o n managing parental

co nce rns there are few attempt tote t any trategie [I r their ab ility to in crea e vacc in e
uptake in the actua l etting of a medical practice . Much of th e re earch th at inform thi s
review is based on non-experimental studi e whi ch make recommenda ti o ns o n the ba
of parental feedback co ll ec ted in the cour e of urveys and focu group di cu

ions .

Given th e weight of ev id ence that und erscores the importance of the role of th e P P
when it comes to influencing parental deci ion-m aki ng proce e , it eem prud nt that
research initiatives examin e tbi m ore clo ely .
To summarize, 10 studi es were selected for closer examin ati on on the ba

of an

integrative review of the re earch literature. From th ese, three theme emerged :
communication content, co mmuni cation timing, and the ob erva ti on tha t th er i a lack of
research th at in ves tigate and identifi e effective communi ca tion trategie to incr a e
immunization uptake in rates vaccine-hesi tant parent . ach of the e th em

wa divided

65
int

ub-th m

on the ba i

f trat gie de ign d to communica t vac 111

a~ ty to

va ine-h itant caregi er .
The~ llowing di cu

relat th m toad

i 11 will examin e the e ub-tb me in grea t r d tail and

i ion-making pro e

that inv lve both mem ry and r a oning, a it

i und r tood in th contex t f fuzzy-trace th ory. The di cu ion will a! or fer t
upporti

r ear h literature that ub tanti ate th applicabi lity of the ub-th eme to

primary care practice in

anada and gi

affect vaccine deci i n-making t day .

c n ideration to th e multiple inOuenc

th at

66
HAPTER4
Di cu ion
An int grati
trat g1

re

w f the literature wa underiaken in rder t identif-y

that P P could employ to communicat

th immunization uptake rat D r he itant careg i

accme afety and thereby increa e
r .

t tal of e ight re earch tudie and

two re ear h review ofD r d

mer commendations with r

trategie .

r the re iew pr

ne of th e tudi e

particular trategy but in tead offered u e ful
findin g

pect to potentially effective

id d tr ng vid nee t ward any

b erva ti n abou t trateg ie ba ed n th

f b th e perim ntal and non-experimental re earch. All th e

indicate th at there i a n ed form re r earch t

upp rt th e e rec mm endati on .

The D II wing ec ti n of thi paper wi ll di cu
th e cour e fthi re iew

urce reviewed

the ub -th emes that m rged in

a wel l a in th e grey literature

and will refer to further

re earch for additi ona l per pective on the finding . The th eme wi ll be a l o be examin ed
w ith re pect to th e way in w hi ch fuzzy-trace theory m odel memory and rea o nin g . And
finall y, the e theme will be co n idered in th e contex t the

anad ian Immuni zati on Guide

recommend ati on for communi catin g effecti ve ly about vaccina ti on. Following thi , the
recommend ation wi ll co nclude thi paper.

S ocial Orientation and Child-Centred Vaccine Communication
Providing scie ntifi c ev idence i m eant to a ist in informing ri k-and-benefit
discu ssions wi th caregiver . Immunol ogica l cience demo nstrate th at th e benefit of
vaccination ex tend beyond the indi vidua l and ha s an impact on th e hea lth of the wide r
community . Hi gh vaccin ation coverage leads to herd immuni ty and prot ct vu ln erabl e
member of the population from the pread of co mmunica ble di ea e . P P , we ll aware
of th e sc ientifi c findin g , may fee l comp ell ed to hare th

e ev idence-ba ed fact in order

to advocate for the protective as pects of wide pread immuniza ti n, and th ereby prompt an

67
altrui tic rep n

111

accine-he itant car gi er . H ndri et al. (2014) inv

ti gated

" vaccin m e ag framing" and fi und that th re i no ba i for takin g a fact-orient d
approach to corrm1unication ; they ad i ed that in tead, P P should tre

vacc me

benefit to th indi idua1 child when p aking with vaccin -he itant r re ista nt caregiv r .
A pre iou ly di cu ed in th e 'finding "
condu c t d a

mp nent ofthi paper, Reich (2014)

c i I g ical tud y of 25 m oth er li in g in

1 rad to e amin e the gend ered

di c ur e of vacc ine r fu a!. The parti cip ant we re int rvi ewed betw
11 the e m o th er
ch

ith r r fu

n 200 7 and 201 .

d to vaccina te their children , or all wed om e vacc in

ing an alt m ali e accin e chedul e . Re ich found th a t the

m o th er w er fi

by

u ed

olely n th eir own c hildren , and th a t they eva lu a ted, and oft en rejected, th e a serti on th a t
the ir cho ice und ermine c mmuni ty hea lth . A t th e a rn e tim e, th e e moth er were abl e t
ignore th e b nefit of herd immunity to th eir own children . Re ich a ttribute thi to a
m odern pare ntin g phenom e non, w hi ch ee ca regiver in ve tin g ub tanti al r
the deve lopm ent of th eir own children, and le

ources In

concern d about th e security and

deve lopment of all children. Reich argue that modern -day pare ntin g trend , pari icul arl y
evident in more afflu ent fa m ili es, influences th e way in whi c h th e e parent make
deci ions about hea lth care. T he pa1iicip ants in R eich ' s s tudy often referred to th eir
" freedom ," i.e ., to choose their health care provider , to manage th eir child ' nutriti on and
their medi ca l care , and to conduct th eir own research , given th eir mi tru t of hea lth
inform ation generated by m ain tream in tituti on . Reich notes th at th e e id ea about
freedom are particul ar to th e privileged and wea lthy, and no t repre entative of oth er
socio-dem ographic groups in the U . She sees child-focu ed hea lth care decision-making
as a symptom of a prevailing c ultural norm whereby mo th er h ld them selve uniq uely
re pon ible for th eir children ' success, fa ilure, hea lth, and di abili ty . E enti ally, ifthi
cultural norm indi cates th at m others take on thi leve l of re pon ibili ty in their children'

68
li

, it al

cane

indicate that th ir ~ cu will b pia ed quar ly n the level

rei e within their own family , makin g th m 1

f contr 1 th y

lik ly t con id er h w their

h altbcar d ci i n-making can impact other children.
The di cu
deci ion with r

ion of child-centred
p

mrnunication and how caregiv rs make

t to accinati n- ba d n p rceived indi v idua l health need in lead

of th e n ed of th e co mmunity-

an be

en in li ght of the tenet of fu zzy- trace th eory

(FTT). Thi th eory id ntifi e D ur a pec t th at have an impact on th e pro ce

m d 1 of

acc ine d ci i n-making : kn w ledge, repre entati n (gi t and v rb atim) , retrieval of
ing (Reyna, 201 2) . Valu e in the FTT repre nt th e relevance of key

valu

, and pr

va lu

or kn ow l dge in c nt

t; proce

in g in o lve und er tandin g f h w va lu e appl y

to th e option o f vacc in atin g or no t vacc in ating.
R eich (2 0 14) note that when nego ti a ting vacc ine- related communi cati o n,
health care practiti oner und e re timate th e way in w hi c h careg iver , u ua ll y m o th er ,
trateg ically nego ti a te y mbo li c, va lu e- laden terrain in m akin g hea lth care deci ion fo r
their children . pec ifi ca ll y, hea lthcare prov ider tend to pl ace in~ m1a ti o n at th e fo re fro nt
of their communica tion th ereby nega ting the fac t that inform ati on alone do s not
influence a caregiver ' decision to vaccinate . T he i u e of vacc in e he itancy or refu al is
symptom atic of la rger sys tems of m eanin g, whi c h include caregivers' des ire to optimi ze
the hea lth of their children and their emph a i o n th eir unique needs (and th eir lack of
interes t in prom otin g generic health po lic ies) . The co mbin ed influence of today's cultural
norms around m o thering, and the a ociated nu anced va lue th a t pl ace an emph a i of the
uniqueness of the individu al child 's hea lth, are een to have a signifi ca nt influence on
vaccine decision-making.
A ccording to the FTT, not only do these factors influence th e con truc tion of gi t
representation of vacc ination tha t will inform d ci ion-making, th ey affect th re trie al

69
f a lu

and proc

ing. The

n iderati n , i .. , which fac t r influence parental

a c m d ci i n-making, and h w paren t intrin ically make deci ion , provide in igh t
a to why healthcare practiti ner
making pr ce
do pr

tru ggl in th e ir attempt t influ ence the deci i n-

. If in~ rm ation a l n d

not impact the dec i ion to vaccinate, how then

id er co ntend with th m any o ie ta l ~ r e th a t affec t the deci i n-making
t which caregi

fram e vaccina ti n di

u

r ar

ubj ect.

a ed on th findin g in thi rev i w , P Ps who

ion in a child-centr d way, and fl cu primarily n individual

benefit ra th r th an emph a ize tb co ll ec ti e b ne fit m ay ha e th e pp rtunity to increa e
accm uptak in a cin e-h
The fo il wmg

itant fa milie .

c ti on ofthi di cu i n w ill addr

findin g fr om thi integrati ve

rev t w that mi ght h lp hea lth ca re practiti oner c unterva il th e oc ietal fact r tha t effec t
vaccine he ita ncy.

Post-modernism ,

arrative Medicine, and Medical Profes ionali m

M cMuJTay et a l. (2 004 ) note th at health care prac titi one rs tend to re ort to th e
cogniti ve defi cit m ode l for tru cturin g th e ir co nver ati on w ith vaccin e- he ita nt parents
by way of offering science-ba ed info nn ati on in an effo ti to qu e ll vacc in e concem . Th i
is dem onstrated in the literature that ba been created to supplem ent hea lthcare pro vi der
knowledge of immuni zation in an effort to inform th e inform ati on they hare with th ei r
pati ents. Offit et al. (2002 ) addressed an increas in g parental co ncern- th a t children
receive too m any vacc inati on and are co n equ ently at ri k of overwhe lm ing their
immune sys tem . T hi "spec ia l article" examined a number of relevant co ns iderations and
concluded that th ere was no cau e fo r concern . The rev iew was set out in uch a way a to
be of m o t u e to hea lth care practitioners requirin g inform ation to co unter anti -vacci ne
c laims and was publi shed in Pediatrics, a wid ely-rea d peer-rev iewed journ al. H ea ly an d
Pickering (20 11 ), in th e ir article " How to

ommuni ca te w ith V acc in e-H e itant Paren t ,"

70

id ntify a numb r of fa t r
th ability to pr vide

entral t

ffi ti e communicati n- whi h they de cribe a

i ntifi fa t by u ing direct unambiguou language, and avoiding

Jarg n and qualifi d tat m nt .
Thi int grati e r

iew includ d thr

pr vid r who w rk with va

in e-he itant r r

tudi

that recomm end that healthcare

i tant caregi er

h uld con ider the

exp ri e ntial knowled ge that parent bring to th c nver ation. Further, tha t pra titi ner
re pond by haring a the ir own heuri ti c kn owl edge, includin g acco unt of th ir vacc inere lated ex p ri nee w ith th er pati nt
McMunay t al. , 2004 ).

(Kemp e et a l. , 20 II ;

ea k e t a!. , 2006 ;

dditi nally, thi re ea rch enc urage hea lth care provider to

tep out of th eir tri ctl y profe sional role and talk ab ut vaccin a ting th e ir own children in
ord er to demon trate th eir faith in immuni za ti on . Th ese reco mm end a ti o n rai e everal
que li on ab ut pr fe i nali m in the contex t f primary care prac ti ce, parti cul arl y w ith
r pect to th e influe nce of pos tmoderni m on h alth care . A di c u ed in th e bac kgro und
to thi paper, ace rdin g to Kata (20 11 ), the po tm odem m edi ca l paradi gm take into
acc ount value a well a ev idence, recogni ze a preoccupati on w ith ri k ove r benefit ,
and ackno w ledge the rise of th e infom1ed pati ent. The effec t of thi paradi gm can be
seen in hea lthcare- w ith the cunent emphas is on shared dec isio n-m aking between
pati ents and P CPs, and th e related shift in the locu of p ower between th e two p arti e
According to Hilton (2 00 8) traditi onal m odels of m edica l profes ionali m in the mid-2 0 111
century were charac teri zed by omni sc ience a nd paternali ti c attitude . The idea that
hea lth profess ionals, parti cularly phy ician , hare torie about th eir own children
requires a ub stanti al leap.
Accordin g to Charon (200 1), deve lopm ent in pati ent-phys ician commun ica ti on in
prima1y care in the 1960 and 1970s placed grea ter emph a is o n th e va lu e f n an ati ve
knowledge in medi cin e.

haron (2004 ) de cribe narrative a a " re-tellin g," a desc riptio n,

71
r a r lating f e ent in a
har d b tw
m

qu ntial and re lati nal way . ln th medi al ettin g, narrati

n h alth ar pr

t fundamental a pect

and pati ent a a unique way f navi gatin g tb

f th human

nditi n.

f medi al

pite han ging n ti n

nali m it ha b n pr p ed that pati ent d e p t

m traditi nal a

f

nali m, u h a a c untability, t dire t th eir phy ician ' prac ti c . H wever,

a

rding t

bar n (20 1) th

in th e fa e ofp ain ... and
re pe t t
tting

am ~ r uch pri ate bene ol en

'a l

mD rt in th e fac

acc in refu al, bene

I nee

n

a tendeme

fd ea th" (p. l 0 ) . It i p

ibl th at, with

ed by way f narrati ve in th medi ca l

uld offer an pp rtunity G r health are pr vid er to engag caregiver in way

th at rn a have an impac t n thei r
appr ac h challenge hea lthcare pr

a ~ ty. Tbi

f mea nin g in relati n t va cin e

ider to a k th em I e ifth ir wn definiti on f

profe ionali m ca n be tretched t in clude toryt !ling by way f per onal and
pr fe i nal narrati v

in rder to pro mot hea lth in th ei r pati ent .

Fuzzy trace th e ry upp ti th e findin g of inco rporatin g narrati ve int vacc me
communicati on in primary car . Reyna (20 12) p int out th at, given th e hum an
preference for fu zzy- proce sing, peo pl e are more likely to u e gi t repre entati n t
upp ort intuitive proce ing and inform th eir decision about vaccinatin g.

arrati ve and

torytelling help to connect th e dot rega rdin g th e benefit of immuni za ti n in order fo r
thee ence and ex peri ence of receivin g th e in fo rmati on can be apprehend ed by th e
audience. From thi , the meaning derived from thi ex peri ence forms th e gi t th at th e
caregiver will prefer to use when making dec i ions about vacc inati on.

nti - acc ine

groups use gi t-laden tori e to ati sfy a longing for clari ty and to expl ai n my teriou
uch a auti m. onvey ing mea nin g through narrati ve in vacc in commun ica ti n
would e enti all y mean matchin g th e gist reprc ntati on of th e anti - acc me mo ement
with gi t from th e infotmati on bared by P Ps when di scu ing vaccinati n .

72
arrativ

and t 1yt lling can al

a

i t a primary care pr vid r to count ract

me f th diffi ult argument put forward by anti-vaccine gr up . Deniali m ha long
been a tactic u

d by anti- accine web it

to addre

cten

that upport vaccin ation

(Dube et al. 2013) . Dieth lm and McKee (2009) define denia li m a " the mployment of
rhet rical argume nt t give the appearan e of legitimated bate wher th ere i n ne , an
appr ach that ha th ultim ate goal f r jecting a propo ition on which a scientific
on en us e i t , (p . 2) . D eni ali m 1 nd it e lf w 11 to chall nge r di reg rd the
ci n e-ba
mu ch I

d inft rma ti n hea lth are pr vi der c n ey to their pati ent . It I nd it e lf

-we ll t re p nding to th ex perienti al knowledge a hea lth care provider mi g ht

ha re with a ca regive r, e pecially w hen th e hea lth care pr vider c nfid e information
about hi

r her w n c hildre n. D enyi ng th e hea lth care provid er ' per onal ex peri ence

would contradi ct th e p

t-m dem belief th a t va lue and par nta l e peri ence m atc h or

up er ede cientific evidence . lt would behoove hea lthcare prac titi ner to putt g od
u e orne of th e tact ic u ed by the anti- vacc in e movement

to he lp promote pro-vacc in e

co mmuni ca ti on in primary ca re.

Prenatal Vaccin e Communication
Of th e ten tudi e rev iewed, three addre ed the theme of prenata l vacci ne
infonnation (Glanz et al. , 20 13 ; Saitoh et al. , 20 13; Vatmice et a l. , 20 11 ). Two tudie
repotied th at providing vaccine information at th e prenatal stage co uld increase vacci ne
uptake in vaccine- hesi tant careg iver . Vannice et a l. (20 11 ) found th at caregivers wou ld
prefer prenata l vaccine communi cation to co me from their hea lth ca re provider in ord er to
h elp inform their decision as to whether or not to vaccina te th eir infants . R esearch that
examined the timing of when caregiver m ake their vacci ne deci ion

upp otis the idea of

earl y immunization discussion . Brunson (20 13 ), looking a t how parent make deci ion
about vacc ination , found that patiic ipants be am awa re of th e prospect of vaccinatio n

73
during pr gnancy r h rtly after gi ing bi1ih . Kenn dy, La ail

wak Ba k t, and

an dry (20 11) urveyed parental confid nee with re pect to vaccine and fl und that m
parent

ought infl rmation ab ut va

t

ine afety before taking their child to be vaccinated.

Th.i r earch ugg t that th r i large gap in th e time betw en wh n caregiv r begin
t think about and I

k int vaccination on their own, and th e time wh en more :G rmal

di u ion u ually take place with th eir primary care pr vid er or public health nur e.
In Briti h

olumbi a if immuniza ti on are not di cu

d with a mother pr natall y

r durin g th immedi ate p tnatal peri d, th fir t pportuni ty i ge n rall y at the fir t
appointment with th e infant' primary care pr
month later. At thi time, if th R urk

id er anywhere fro m one w ek to one

a by Record (Rourke, Ledu c, & R urke, 2014) is

u ed to guide the a e ment and edu ca ti n barin g durin g th e appointm ent, th
practiti on r i obli ged to di cu

immuni za ti n pain-redu cti on trat gie and record any

vaccination alrea dy rec ived. The e chart do not come with guid eline for th e
practitioner in addre ing parental co ncerns pri or to th e admini trati on of vacc in ati on
typi call y at th e age of two month .
The trength of the prenatal immuni za ti on edu cati on trategy i th at it would be
relatively easy to adapt the edu cati on provi ded durin g prenatal appointm ent to include
vaccine-related info rm ati on. It a! o could be add ed to th e curri culum of prenatal cla e .
The most noti ceabl e weakn ess of such a trategy is that th e potenti al of educational
interventions at the prenatal stage is no t suffi cientl y well-re earched to single it out it a a
succe ful strategy that would enco urage provider to inco rp orate infonnati on se ion of
this nature into th eir practi ce.
At present, studi es by Saitoh et al. (20 13), and by Zuni ga de

un cia et a!. (2003 ),

provi de th e only research that looks at prenatal immuniza ti on edu ca ti on for it potentia l to
increase vaccin e uptake. The Zuniga de Nunci et al. (200 ) tudy wa

xc luded from

74
th i re i w b au

it I

k d at du ati nal int 1 enti n in an under-vac inated pr natal

atin p pu lati n, and b cau e it wa no t c ncerned with increa ing vac in up take in
th

wh wer philo

phica ll y pp

in teg rati e literature rev iew
riti h

lumbi a

it w uld

dt

accina ti n. Ba ed n the findin g

and taking int
em tim I t ad

f thi

n id ration th l w ac inati n rate
at for r

111

arch th at examine th

1mpa t f prenatal edu ati n interventi on th at are initi ated in th e primary are ettin g.
uzzy-trace th e ry

nce ptuali ze th e prenatal p ri od } r fir t-time caregiver a a

m m nt wher th e are at ri k ~ r a "m anin g threa t," whi ch Rey na (20 12) de cribe a a
ga p r a c nfl i t in un d r tanding th at in rea

the de ir

~ r mea ning. W

men wh o

bee m cogni za nt f a cin e ri k durin g pregnancy are Iikely to e peri ence thi
in r a ed de ire ~ r und er tandin g a th y prepare t

va lu ate th threat enefit

propo iti n with r p ct t th e hea lth of th eir unb m child . At thi ea rl y tage, acco rdin g
to Reyna (2 0 12), mea ning i m

t likely t b d ri ved fr m minimal kn ow ledge,

peri ence, bi a, be li ef about pi au ibili ty, and I w leve l of ex pos ure to au al narrati ve
in fir t-tim e parent . lt eem th at, durin g thi impre i nabl e peri od, a parent begin
their ea rch for mea nin g, prenatal edu ca ti on, or eve n an inform al di cu ion, wo uld h lp
to form a gist repre entati on th at favour vacc inati on.
Th e Canadian Immunization Guide and th e B CCD C Immunization Communication
A SK Tool
There are no evidence-ba ed practi ce guid elin e m anada to advi e hea lthcare
providers on be t practi ces in communi catin g with caregiver who are phil o ophi call y
oppo ed to immuniza ti n . However, both federal and provin cial health bodi e prov ide
recomm end ations on how que ti n th at r late to vacc ine afety ca n be addre ed, and
how hea lthcare provider can initiate immuniza ti on di cu ion with th eir pati ent . oth
ource offer inva lu able informati on to hea lthcare pr vider . Th e anadi an lmmuniza ti n
Guide (Publi c llea lth Agency of an ada, 20 l 3a) and th e Immuniza ti on

mmuni ca ti n

75
T ol (B

, 2 01 ) are d

igned t in~ rm the practice f healthcare provider wh

admini ter th vaccin ation along with providing inti rmation about c mmunicating
vac ine afety.

iven that P P generally do not admini t r vaccinati n , they may n

r fer to th em a frequ entl y a the key point about vaccine afe ty are emb dd ed in
in~ rmation regardin g t rage and admini trati on

The Publi H alth A gency f
ati na l

f immuni zati n .

anada ha adapted m a teria l pro v id ed by th e

dv i

ry

mmittee on lmmuni za ti n ( A 1) to pr du ce th e

lmmuni za ti n

uid

an nl ine re

immun iza tio n prac ti ce . T he

an adi an Immuni za ti on

o ptimal immuni za ti on practice
profe

urce for hea lthcare pr

ana di an

id er when it com e to

uid e et

ut 16 guide line for

w hi c h are rec mm ended for u e by a ll health

iona l w ho admini ter vacc in e or manage immuni za ti on ervi ce (Publi c H ea lth

gen cy of

an ad a, 20 I 3a) .

T he e guid e lin e provid e a grea t dea l of infmm ation on how hea lthcare
profe

ional sho uld approach their ro le a vacc in e prov id er to de li ver accessibl e, tim e ly

inform ed , and afe immuni za ti on . For prov ider un sure of th e role a vacc in e prov id er
play , th ese guid elin e

pecify the comp etenc ie for eva luatin g immuni zati on prac ti ce ,

id enti fy in g defi c ienc ies, areas of excell ence, and re o urces needed to ac hi eve
immunizati on goa ls. T hree guidelines apply to th e issue of vacc in e he itancy ; th ey
describ e wh at health care providers should kn ow in advance, and reco mm end way in
w hich to communi ca te to a pati ent regardl ess of hi s or her po iti on on immunizati on
Non e of the guideline direc tly address the i sue of vaccine he itancy or refu sal.
A ppendix C in cludes a tabl e of the three guide line re levant to thi s paper (Guideli ne 4, 5,
and 6) .
T he online

anadi an Immuni za ti on

uide in clude link embedd ed in gui d line

fo ur and fi ve w hi ch brin g up a separate webp age w here key po int

e t out effec ti e

76
c mmu ni ati n princip le . H re vaccine he itancy i defined and fact r influ ncmg
that, t c mmuni at effective ly
ab ut a

inati n wh n re p nding t va cine h itancy, ne mu t adopt a ac me-

reclpl nt- entr d appr ach , r p ct differen e
th ri k and benefit

f pini n abou t immunizati n repr

nt

f accine fairl y and penly, and ommunicate cl early ab ut

urrent kn wl edge by rei ing n an e idence-ba ed approac h.
The rec mmend ation t pr
with th e findin g

id a accine-recipi nt- entred appr a h i c ngru ent

f thi re iew . F r e ampl e, Hendri x et a!. (20 14) ~ und th at child -

c ntr d c mmuni cation in rea e th e intenti n to accin ate. Much f th e re t of th e
in[! nn ati n in th e

uid e, a it concern effecti e ommuni ca ti n, centre

n th e evidence

th at ca n be u ed to refute claim of levated vacc in ri k . Reco mm end ati n empha 1ze
th at uffi cient tim e be taken t di cu

vacc inati n, th at a re pectful mann er be u ed,

jargo n be avo ided, and cience- ba ed infonn ati on be pr

ided. The guid e emph as ize th at

"regul ar hea lth care prov ider , uch a vaccin e provider , are perceived a tru ted
individual and have a vital ro le in en urin g co ntinued ucce
and in maintaining co nfidence in th e effecti ve ne

of immuni za ti n program

and afety of vacc in e "( Pu bli c Hea lth

Agency of an ada, 201 3a) .
A noted above, in Briti h olumbi a, health provider

uch a famil y doctor or

nur e practitioners rarely provide vaccine . Dependin g on the caregiver' relati on hip
with the taff at hi or her publi c hea lth centre (where children in th e prov inc are
typica lly immunized), th e vaccine prov ider is j u t a likely to be a regis ter d nur e
unfamiliar to the famil y. Wheth er or not the nur e i perce ived a a tru ted indi vidual
wo uld likely be more dependent on th e ex tent to which a generalized

n e of tru tin

hea lthcare prov ider ex ist in th e ab enc o f an e tabli h d relati on hip .

77

Th

riti h

o lurnbi a

entr for

ontrol ha d veloped th Immunization

1 ea

mmuni ati n To 1 for lmmuniz r (B

, 20 13). Th r

int grative revi w i primarily con ern d with the " how
th way in which health ar provid r

on

arch con id red for thi

f vaccine comrnunicati nor

yin[! rmation to caregiver in hop e of

incr a in g immuni zation uptake rate . The B

D

communi ca tion t

with th "what"- the c ntent, or a tu a l in[! rmation that hea lth are pr
rd er to an wer pec ifi c qu

I i concerned
id er n

d in

tion abo ut vacc in e afety . Fore ample, on findin g that

m rged in the c ur e of thi re iew wa th a t vac in information hould be tran mitted
earl , durin g the prenatal peri d . The Immuni za ti o n

mmuni ati n T ol (B

D

20 13) pro ide infonnati n approp riate for thi ea rl y tage with re pec t t vaccme afety,
vacc ine ingredients immune v rload, thim ero o l, and auti m (B

D , 20 I ). lt al o

provide evide nce to refute th e prevailing view po int of anti -vacci ne gr up and
tran late the c lini ca l jarg n int plain

ng l i h.

Inc lud ed in thi document is th e A K tra tegy for effecti ve immuni za ti on
communica ti on : Ackn ow ledge your c li ent ' c ncern ; Steer th e co nve rsati o n (to refute
myth or clo e the conver ati on if th e c li ent i a co nscie nti ous objec tor) ; Kn owledge
(know the facts well ). T hi

trategy exemplifi es an evid ence- based re ource avai lab le to

bea ltbcare provi ders to suppl ement th eir knowledge of childhood immunization ,
compl ete with tips on how to initiate con versa tion s with th e ir pati ent .
It is important to note that both the Canadian Immunization Guide (Pub! ic Health

Agency of

anada, 20 13), and th e lmmuniza ti n Communication Too l (B C D , 2013)

offer exce llent evidence-based information well-suited to addre

th e concems of

vacci ne-hesi tant parents. However, g iven that th e information m ay not b acce

da

frequently by primary care providers, who do not typically provid vaccine , they may
not be aware of it de pite their role as frontlin e advi or to caregiver with re pect to

78
ac ine-r lated d ci i n . Jd ealJy, th informati n g n rated by fed raJ and pro v in ial
auth ritie
and influen
m

h uld b dire ted to all h alth are pra titi ner w h are be t pl aced to advi
th deci i n-making pr

e e to w hi ch caregivers are ubj ect to w hen it

to d v lop ing their under tand ing f vaccine-rela t d i ue .

79
H PT RS

Recommendation and
[twa th intenti n f thi in t grati e r
pnmary car pra ti ti ner in the pr

e

onclu ion

iew t I

ka t e id nee that c ul d inft rm

f w rkin g with a

in -he itant caregiver . In

th c ur e f thi r icw, three pre a lent ub -th me were id ntifi ed: chi ld-centered
c mmuni ati n nan·ati e acc ine
Th

mmuni ati n, and prenatal acc me

mmuni cati n.

th m

w re linked t h alth are practi ce by way f upp rti ve lit rature fr m th e

b ha i ural

and th e fu zzy- tra e th eory appr ac h (Reyna, 2 12). urrentl y, much

of the inG rm ati n pr

ided t

upp rt practi ce hin ge

n edu ca tin g P P with re peel t

th e argum ent to refute anti - acc ine claim . II we er, it fail t a kn wledg th
c mpl e iti e
qu

f th e influence t whi ch caregi er are ubjec t t when it come t

ti nin g th e aD ty f a c in e , or refu in g to vacc inal th ir children. h fo ll ow in g

ecti n will include recomm end ati on for practi ce, re earch, and edu ca ti n with re pect t
th i ue of acc ine he itancy, th e findin g of th e rev iew, and th e upp rtin g literature
th at infonned thi proj ect.

Recommendations fo r Practice
The i ue of vaccine he itancy i of parti cul ar imp rtance given th e low vaccin
uptake rates in Briti h olumbia- whi ch are seen to be re ponsibl e fo r th e regul ar
outbreak of vaccine-preventabl e disease , event th at we re previ u ly kept to min imal
level in th e province (B

D , 20 12) . Wheth er or not th e i ue of vacc ine he itancy r

refu sa l i entirely to bl ame, th e low rate of vacc in e uptake noneth ele

pre ent a

signifi cant health threat to both indi vidual and po pul ati on hea lth . It i imp01ia nt th at P P
und erstand how th eir practi ce influ ence th e dec i ion-making proce

f careg iver wh

are un ure about whether to vaccinal th ir children, r wh o are refu ing vacci nati n
alt gether.

80
en th ugh the finding
r

arch th y d

ffer u ful re

f thi re i ware n t derived fr m a large b dy f
mm ndati n that

addre ing a cin he itati n in wa

that are le

th ir relati n hip with th eir patient . Th re
in~ rmati

n, to u

narrati e to di

u

uld a i t P P when it c m

likely t ha e a negative impa t n

mrn endati n

pr

id child- ntred

p r nat e p ri nee with imrnunizati n , and t

begin the acc m -r lated c mmuni cati n durin g prenatal appointment dif[i r fr m th e
n enti nat re

mm ndati n for h alth are pr

ider t date. Th e re

rnmendation

prov ided here endea our t in e t acc in e c mmuni cati on with m r mea nin g th an it
would hav we r itt rely
to

!ely n th e tran mi i n of cientific fac t a th e only mean

nvince a he itant ca regiver f th e

a ~ ty

f vacc ine .

It i imp tiant th at hea lthcare pro ider take th e lead and intr du ce thi topi c t

par nt rath er th an find th em el e in a reacti ve po iti on when parent intr du ce th eir
acc me co ncern . The co nfidenc

n ey d by th e hea lth care prov ider when intr du cing

th topi c th e engagement th e pati ent fee l at th at moment, th e kn wledge gain ed

and

eve n a naJTati ve bared- will all a i t i n~ rmin g the gi t and verbatim repre entati on
upon which th e pati nt wiII draw in th e proce

f makin g vacc ine-related deci ions

(Reyna, 20 12) . Jt i argued here th at th e trength of thi gi t repre entati on will influence
how a caregiver will react when faced with anti -vacc ine inform ati on. Id ea ll y, PCP will
approach vaccin ation di cuss ions with mea ningful , evidence- ba ed an wer to th eir
pati ent ' qu e lion . Ideall y, too, they will initi ate uch di cu ion durin g th e prenatal
stage before parent beg in to form their que ti on - and before th ey have time to fom1
th eir oppositi on.
P P who are th em elve un ure about how to re pond to qu
safety have ava ilable to them th e anadi an Immuniza ti on
Immunization

ti on about ac me

uid e a we ll a th e B

mmuni cati on To I. The e re ource repre ent appropri ate and

81
up-t -date in~ rmati n and wi ll upp lement P P k.n wl dg ab ut a ctn
e pe ially given the e t nt t whi h th

mak

afety-

a c nc rted fD rt t ke p abr a t

f th late t anti- a cin pr 1 o iti n and g nerate re ent updat

th re

urc ma t rial

Recommendation f or E du cation
P lly et a!. (20 l 0), in th eir a e ment f h alth edu ca ti n tn
that gradu ate

an ada cmpha iz

nal program in h alth lea e th ir tudie with ignifi cant ga p

in thei r und er tandin g f a ci nati n-r Ia ted t pt
[i und th at grad uate

. pecifically, th auth r

f thi

tudy

Jack uffi ci nt inD rm ati n when it c me t re pondin g to qu e ti n

ab ut a ci ne indi ati n and contraindi ca ti n , ad er e e ffect , and afety. It i worth
notin g that th
phi I

t u

phi all y pp

areal o th
e vacc tn

cm

t fr qu ntl y identifi d by parent who

. Healthcare practiti ner wo rkin g in primary ca re r

pedia tri c ettin g wi ll likely enc unter famili

and individual who h

e not to

vaccinate on the ba i of th ei r belief: , and wh c n idcr th em elvc phil o ophi ca ll y
oppo ed. Wil

n (200 ) argue th at th lev I of pr paredne

th at h alth practitioner

brin g to thi interaction could have an impact on th e dec i ion th at ca regiver make a
whether or not to vacc inate th eir children. uffi cient knowledge abou t vacci n ri k and
benefi t provides a trong foundation from whi ch P P can convey confidence and build
meanin gfu l di cus ion wi th their pat ients. If hea lthcare provider in primary care fe I
uncomfortab le an werin g qu e ti on du e to lack of knowledge, tim e con trai nt , or are
them elve he itant, th en th eir uncertainty will inevitably be communi cated to patient
looking to have their own uncertainty va lidated .
ln order for primary care NP to feel c nfident ab ut co nveyi ng vacci ne-relat d
information t th eir pati ent , reliabl e information th at cover th e i u

f a ci ne

hes itancy and r fu a! hould be included in th eir edu ca ti onal program

e peciall

82

th

p

h

t t

be in

d in family practi

th ir und r tanding f the fact and feel

. In thi way, P P will ha e

me hat prepar d tore pond t

vac m argum nt by c unt ring withe id n e [! r the
tim

di cu
n

1

a~ ty

fva

lidifi d

omm n anU-

ine when it c me

th t pi with aregi er .
ue that i glarin g! ab ent in th literature r

iewed [! r thi pr j ect i th e

a knowl edgement th at ther may be P P and nur e wh th em e lve ha e d ubt ab ut
the afety f a

ine . Hea lthcare pr

id er wh are criti ca l f vac in e have th

pot nti al t und ennin publi c co nfiden e in immuni za ti n , parti cul arl y if th ey h
hare th ir iew in a publi

[i rum . lt i

e

ntial to en. ure th at hea lth ca re pr fe ional

begin th eir care r with full kn ow ledge ab ut th e urrent va cin e debate in rd er to
n ure onfid nt rec mm nd ati n in fa

ur f vacc in ati on.

R ecommenda tion ' for R e 'earch
Th tw r ea rch re iew inc rp rat d in th e findin g for thi int grati v rev1ew
indi ca te th at th ere i a pro ~ und need D r re ea rch th at I

k m re cl ely at interventi on

a th ey relate to vaccine- he itancy . lt eem th at a tremend u am unt of re ea rch ha
been und ertaken in ord er to better und er tand th e demographi c of vacc in e-he itant
caregiver , their belief , how th ey make deci ions, and what in[i rm th eir dec i ion . But,
th ere i criti ca l hortage of re ea rch th at looks at interventi on th at are pec ifi call y
ori ented toward increas ing the intention of ca regiver to vacc inate. on equ entl y, th ere
is a! o an absence of u eful strategic for guidin g hea lth care prov ider as to what may
work. Perh aps th e he itation to conduct thi kind of re earch ha to do with th e rea liza ti n
th at it i diffi cult to nail down a one- ize-fits-a ll trategy given the multitude of fac t r
which caregivers are obli ged to con ider.
The findin g th at have emerged from thi integrati ve re i w ugg t th at further
re earch mi ght c n ider examining th e utcome of inc rp oratin g a vacc inati n educa ti on

8

m dul int pr natal cia e in a g

graphic ar a known t ha

hildr n and anal z wheth r thi w uld increa
ac m uptak rate in the oh ti
relati

trai ght~ rward re ear

ly

dep nd n the careful de
ample vid nee t
wh ar m

h pr j

1 w accm

v ra ge

th intenti n to va

inate, r

p ed t th e m dul . Thi would be a
t. Th e quality

f th e re arch w uld h w ver,

I pm nt and deli ery f u h a modul

given that th ere i

ugge t th at inD rm ati n in it elf i in uffi ient t c mpel th e parent

t lik l t be he itant about a cine t immunize th eir children. Th e m dul e

uld need t

111

rp rate a e tudie an

parent in th e pr natal cia

r per onal narrati ve t whi ch pr

pe ti ve

can r Jat in ord er fi r th em to d ri ve meanin g and tr ng gi

r pre ntati on fr m uch an e pen ence.
pr ject f thi nature, pro ided to pr
de ign d to addre

pec ti ve parent

al ng with in[i nn ati n

anti -vacc in e claim th at mi ght come up durin g a prenatal cia

could ffi r a valuabl e r

arch pportunity to ee if prov idin g earl y, mea nin gful ,

informati n on vacc ine bring about hi gher rate of vacc in e uptake. Thi
recommend ati on for r earch in v lve tryin g to in c rp orate an up tream interv enti n,
where informati on i tran mitted earl y in th e child-rearing proce s, before parental idea
becom e full y form ed and entrenched.
Conclusion

Vaccine he itancy foll owed by vacc in e refu al has re ulted in a ignifi cant hea lth
problem for Canada. Declining vacc inati on rat

in young children have ca u ed an

increa e in vacc ine-preventabl e communi ca bl e di ea e due to increa in gly low herd
immuni ty . P P continue to be th e main source of vaccin e- related inform ati on [i r
concern ed careg ivers and parent . Thi integrative literature re iew ha e amined th e
ways in which nur e practiti ner - a primary ca re provider

can mer a eva

111

uptake for pati ent in their care. Thi di cu ion al o pro ided a hi t ri ca I background to

84
a cme PI
pr

iti n and c n id r d the modem -day inDu nee

t whi h car gi er ar

ubject wh nit c m

n iderati n highli ghted th e r levanc

n the deci i n-making

t va cine afety . Th

f thi t pi c t primary car and

P practice.

arch, and the findin g fr m
th

tudi e

in~ rm ed thi

trat gre th at ar be t ac hi

re iew and fl r ground ed e era] key th eme

communication

ed by being hild-centr d, narrative ri h, and tim ed t

cur

at th prenatal tage.
Th e th em
c nte t f e

we re di cu ed in th e findin g

ti n ab ve, and e amin ed in th e

luded tudi e , grey literature, andre earch from beha ioural

· uzzy- tra e th eory wa appl ied to th e findin g

fthi integrati v

renee .

rev i ew ~ r it

ability to

bring in ight int th e way in whi h parent make acc in e-related de i i n , and to
hyp th e ize wheth er th e e trateg ie could be effecti e G r vacc ine c mmunica ti n.
R c mmendati n

[i r pra tice were di cu

ed al ng with ugge ti n

~ r furth er re ea rch.

The need for furth er r ea rch i of pari icul ar imp rtance du e t th e fac t literature
rev iewed h rc ind icates there i a hortage of re ea rch to inform hea lthcare pr vider
about whi ch interventi on are mo t likely to increa e vaccin e intenti ons and uptake
It i hoped th at thi proj ct will hed li ght on th e i su of vacc ine he itancy a a

way of enablin g nur e practiti oner - and all primary care prov ider - to under tand th at
parent and caregiver do not ac t imply on th e ba i of a di ffe rence of opini on, or a lack
of kn owledge, when it comes to makin g th e deci ion not to vaccinate. There i , currently,
a multitude of intemal and extemal fac tors th at influence vaccine dec i ion-maki ng orn e of whi ch n ur e practiti oners have an op portun ity to addre .
Thi s project a

ris th at meanin gful vacci ne communi ca ti on tl at i child-centred ,

includes narrative, and begin ea rly co uld help nur e practiti ner influence th view of
parent and caregiver with re pect to childh

d vacc inati n, and in thi wa better

85
inti rm th de i i n-m akin g proce . Th ultimat g a! f th
int rventi n

1

to d crea

the rj k fi r ac in - preventable

m rta lity fl r b th indi v idual and the communi ty as a whole.

e

mmum ati on

mmuni able di ea e a nd

86

REFERE
dam

E

n P. (2 1 ). Inn c nti r p rt ard I I : hild well-b ing in rich c untrie .
1 F. R tri
d fr m
http ://ww
/d fau l
R%20W R
/uni ef_r p rt ca
Tl /P
rd_ l l .pdf

et ch, ., Renkewitz, F., et ch
riti al eb ite n per e1 tn g a
15( ), 44 -4 5.
Bl nd ll, R. L. , Fehr, J. L. (20 12) .
Journal of Perinatal
d i: lO . lO 7/JP .ObOJ

1 hofer, . (20 10) . The in flu nc f va mein ati n ri k. Journal of Health P ycholo
u in g ac inati on with c n rn ed pati nt . Th e
' 26( ), 2 0-241.

rain rd, . J. , Re na, . F. (200 l . Fuzzy-tra the ry : ual pr ce e in mem ry ,
r a nin g, and gnitJ ve neur ien e. Arh ances in hild Development and
Behavior, ] , 4 1- 100.
riti

entre for Disease
lumbi a entre ~ r 1 ea e ontr I. ( 19 9) . 199 B
ontro l: Annual summary of repo rtab le diseases. Retri e ed fr m
http ://www. b cdc.ca
rd nl yre /49 974 F - 1A9-457 A- 84 2 4 18 164 5/0/ pid_ tat _Re earch_ DAnnualRep rt_ l 98 .pdf

riti h
lumbi a entre for i ea e ontr I. (2 009). immun ization in Briti h olumhia,
2006-2007. Vane u er:
entre for i ea e
ntrol. R tri ev d fr m
http :/ j www.bccdc.ca /NR/rdonly res jOBD97048-0428-469 8-ACA0 11 FS 1AD6 F046/0 /1 mmuni za tionRe portBCCDCfin aiCol ourpdf.pdf
Briti h olumbi a entr for Di ea e ontrol. (20 13a). British olwn bia annual summary
of reportable di, ea ·es. Va ncouve r: B
ntre for Di ea e ontro l. Retri eved from
http ://www. bccdc.ca R/rdonl yres/
85 70-804 -4 DB -8A646009 9FD49A3 /0/20 13 D nnu alReportFin al.pdf
Briti h olumbia entre for i ea e ontrol. (201 3b). imm unization communication tool
fo r immunizers. Retri eved from http ://www .bccdc.ca R/rdonl yre /DAD 33 047590-48
- 0 2 -65 0 54 DFC77 ~101 D I To l.pdf
British olumbia entre for Disea e Control. (201 4) . Percent oft11'0-year old -. ,1 •ith upto-date immunizations British olum bia, 2009-2013. Retri eved from
http ://www .bccdc.ca R/rdonl yre /B8FB 94A - 2 16-4A F -B88A5 3 539F2575/0/2_Yea r_Old_Imm _ overage_200720 11 _ oh01i .pdf
Briti h olumbia entre for Di ea e ontrol & Popul ati on and Public Hea lth . (20 12) .
Immuni zeS progre report: April 1, 2007- March 3 1, 20 12. Retri e d from
http ://www. bccdc.ca/NR/rdonl yre /0
07 5-9 6-4 0 92-8 5 9754766995 9/0/ D 2 18lmmunizeB _Boo kl et_FlN L.pdf
Briti h olumbi a. 1mmuni ze B . (20 12). infan t immunizations. Retri e ed fr m
http ://immuni zebc.ca/getvacc inated/infant-immuniza ti on

87
riti h
lumbia . lmmu niz
. (20 1 ).immunization ommuni arion too/for
immuniz r . Retriev d fr m http ://www .bccd . a R/rdonlyre /DAD
04-75904 A - 2 -6 54
77 .. ;o; D 1
I. pdf
rain rd . J.,
Reyna , . F. (200 1). uzzy-trac th e ry: Dual pr c e in memory,
rea ning and c gniti n uro ct nc . Advan
in hild Developm nt and
B ehavior, 2 , 4 1- 10 .
Brun

n, . K. (2 I ). H w par nt make de i i n ab ut their children ' vaccinati n .
Va ine 3i(46) , 54 6- 470. d i: l . 10 16/j . ac ine.20 1 .0 .104

a iday, R. . (2007). hildr n ' h alth and the cia I th e ry f ri k: in
riti h m a le , mump and rub lla (MMR) ntr ver y. ocial cien
Medicine. 65(5), 105 - 1070. d i: l0 . 101 6/j . oc cimed.2007.04.02
nter ~ r i ea e
ntrol and Preventi n. (20 14). Timelin : Thimero al in Vaccine
( 1999-20 I ). Retri e ed fr m
http ://www. d .g I acci ne afety/ ncern /thim er al/thim er al tim eline.html
har n, R. (200 1). arra ti medici ne: m d I ~ r em pathy, refl ecti on, profe i n, and
tru t. Journal of th e merican Medical Association 286( 15 , I 7- I 902 .
d i: lO . IO l/jama .2 6.15.1 97
baro n, R. (2004 ).
2- 64.

arrati e and medicine. eH' England Journal of Medicine, 350(9) ,

allege of Reg i tered ur e of Briti h olumbi a. (20 10) . om petencie required for
ur Prac titi oner in Briti h olumbi a. Retri ev d from
http ://www .crnbc.ca/Regi trati on/Li t /R gi trati onRe ource /416 ompe tencie
p .pdf
a llege f Regi tered ur e f Briti h olumbi a, (20 J I). cope ofpractice for nurse
practitioners. (Publi cati n No . 6 8) . Vancouver, riti h olumbi a: R B .
Davie , P., hapm an, ., & Lea k, J. (2002) . Antivaccination activi t on the wor ld wide
web . Archive of Disease in hildhood, 8 7. 22-25 .
Demp ey, A. F. , Abraham, L. M., Dalton , V., & Ruffin, M . (2009) . nder tanding th e
rea on why mother do or do not have th eir adole cent daughter vaccina ted
again t human papillomaviru . Annals of Epidemiology, 19(8), 53 J -53 .
doi : 10.10 16/j .annepidem.2009.03 .011
Di enso, A. , uyatt, ., & ili ska , D. (2005) . E1•idence-ba ed nursing: A guide to
clini a/ practice. t. Loui , MO : I evier Mo by.
Di eth elm , P., & McKee, M. (2009). Deni ali m: What i it and how shou ld cienti t
respond? European Journal of Public Health. 19. 2-4.
Dube, ., Laberge, ., uay, M., Bramadat, P., Roy, R., & Bettin ger J. . (20 I ).
Vaccine hes itancy: An overview. Hum an Vaccines lmmunotherapeutics. 9( ),
1763- 1773 . doi : l0.41 6 1/hv.24657
ko Re ea rch A sociate Inc. (20 11 ). urvey of Parents on Key i ssues Related to
immunizations. ttawa : Publi c Hea lth Agency of anada.

88
111

P. am , K.,
b?fi tiou Di

Heymann . L. (20 11 ). H rd immunity:
' 52, 911- 16.

r ugh guid . lini a/

r drick n,
., a i , T.
mold . . Kenn n, ~. M. Humi t n, . ., r , J.
T.
B c hini J. . 2004). hildh d immuniza ti n refu al: Pr ider and parent
p r epti n . Famil Medicin e, 36 6), 4 1-4
Fr ed

.,
a i , M. M. (20 1 J ). urc
lark, . J. But hart, .T. ll1ger,
and p rcei ed credibility f a cin - afety informati n fl r parent . Pediatri s,
127( uppl. 1), 107- 11 2. d i:JO .l 542/ped .2010- J722P

Ieman, M. ., Paz I, K.,
azmararian, J.
ren tein , W., Prill , M., Hitzhu n 11. .,
&
ter
. (20 l 0) . Maternal knowledge and attitude
ward innuenza
acci nation : fl u gr up tudy in metr p litan tl anta. fini cal Pedialri s,
49(11) , 101 8- 1025 . d i: l . 11 77/000 922 10 7 946
rbcr, J. .,
ffit , P. . (2 09). a in e and auti m: tale f hiftin g hyp th e e .
fini cal h?fectious Disease', 4 ( 4 ), 456-46 1. d i: I 0.10 6/59 4 76
adi, L. , ohen, M.H., & V hra, . (2010) . hildh d
ilm ur, J., Hani n, .,
immuni za ti n: When phy ician and parent di agree. Pediatri s, 128( up pl. 4 ),
167- 174. doi : I0 .1542/ped .2010-2720 lanz. . M., Wagner, . M., arwaney, K. J. , h up , J. A., Me lure, . L. ,
Me ormi k, . V.,
a ley, M. F. (20 1 ). mixed method tudy of parental
vacci ne deci i n makin g and parent-provider tru t. Academic Pediatrics, 13(5) ,
Hago d, . ., & Herlih y, . M. (20 13 ). Addre in g heterogene u pare ntal c ncem
about vaccinati on wi th a multiple- ource m del. Hum an vaccin es &
immunoth erapeutics 9(8), 1790- 1794 . d i: I 0.416 1/hv.2488
Hea lth anada. (2000). Health anada deci ion -making framework~ r identifyi ng,
a e ing, and manag ing hea lth ri k . Retri eved fr m http ://www.hc- c.gc.ca/ahcasc/alt_fom1at /hpfb-dgp a/pdf/pub /ri k-ri qu -eng.pdf
Healy, . M., & Pi ckerin g, L. K. (2011 ). How to c mmunicate wi th vacci ne- he itant
parent . P ediatrics, 127( uppl. 1), 127-s 133 . doi : IO . I542/ped .20 10- 1722
Hendri x, K. ., Finnell, M. ., Zimet, G. D., turm , L.A ., Lane, K. A., & Down , . M.
(20 14). Vaccine me age framing and parent ' intent to immunize th ei r infant for
MMR. Pediatric 134(3 ), e675-e6 3. doi : 10.1542/ped .2013-4077
Hilton, S. (2008) . ducation and th e changi ng face of medical profe ionali m: From
prie t to mountain guide? The British Journal of General Practice 58(550), 53-36 1.
doi : 10.3399/bjgp08X280 128
Immunization Act10n oa1ition. (2008). MM R vaccine does not cau e a uti m. R tri ved
from http ://www .immunize.org/catg.d/p4026.pdf
Joll ey, D., & D ugla , K. M. (20 J4 ). The effect of anti -va cine con piracy theori on
vaccinati n intention . PLoS One, 9(2), e89 177 . doi : 10. 1 7 1/journ al.pon .00 9 177

89
Kata,

. (201 2). An ti- a cin a ti i t , Web 2. 0, and the p tm d rn paradi gmn
rvi w fta ti and tr pe u ed nlin by the anti - a cine mo em nt. Vac in ,
778-7 9. d i: 10. 1 16/j .va cine.20 1l . l1.11 2

Kaufman J.
nn t . Ryan R. Hill , . H r y, . Willi , ., . .. R bin on, P. (201 ).
Face t face interventi n [! r in~ rmin g or du cating parent about arly childh d
a inati n (r i w) . Th e o hrane Databa o.f ' tematic RevieVI s, 20 l (5).
d i:10.1002/ 146 I
0100 .pub2
Kemp , A., ale , M . ., Me aul ey, M. M., rane, L. ., uh , . ., Kennedy , . M .,
. . . ickin n, . M. (20 11 ). Pr a) n e f parental ncem ab ut hi ldh d
a in : Thee peri n e o f primary are ph y ician . American Journ al of
Preventath eMedicine40( ), 4-55 . d i: IO. lOl /j .amepre.20 10.12.025
Ia er, J.,
II w,
u t, . (2008) . eve I pment f vacc in ri k
c mmuni ati n me age u ing ri k c mpari n and math emati ca l m deling.
Jo urnal of I I alth ommunicatio n 13( ), 7 - 07.
d i: IO . l O 0/10 1 7 0 024874
K nn dy,
heedy, K . (20 11 ). ace in attitude , co ncern , and
inform ati n ource rep01i d by parent f youn g children: re ult fr m the 200 9
H alth ty le urvey . P edia trics. 127( up pl. I), 92- 99. d i: I 0. I 542/ped .20101722

Kenn edy, A., La Vai l, K.,
wak, ., a ket, M., & Land ry, . (20 11 ).
nfid nee about
va em in th e ni ted tate : nder tandin g parent ' perce pti on . Health Affairs ,
30(6), 11 5 1- 11 59 . d i:10.1 77/hlth aff.20 11.0396
Kennedy, L. H., Pruitt, R., mith , K., & arrell , R. F. (20 II ). lo in g th e immun iza ti on
ga p. Th e ur e Practitioner. 36(3), 39-45 .
doi: 10.1097/01. PR.0000393970.2 1436.8b
Laberge, ., uay, M., lement, P., Bramadat, P., Dube, ' ., Roy, R., & ettin ger, J.
(20 11 , December). Work hop on th e cultural and reli giou roo t of vacc in e
he itancy . ultural and relig ious roots of vaccine hesitancy : Exp lanations and
imp lications /or Canadian health care. ymp o ium co ndu cted at th e ni ve r ity of
herbrooke. Retrieved fro m http ://www .u herbroo ke.ca/dep- cience - antecommunautaire/fil eadmi n/ ite /dep- cience - antecommunautaire/document /He itationVaccinati on/ Affi cheMG -ang lai .pdf
Lar on, H. J ., oo per, L. Z. , Es kola, J ., Katz, . L. , & Ratza n, . (20 11 ). ddre ing the
vaccine co nfidence gap. Lancet, 3 7 (9790), 526-535 . doi: 10.10 16/ 0 1406736( 1 I )60678-8
Leask , J., Chapman, S., Hawe, P., & Burge , M . (2006) . What mai ntain parental
upport f r vaccinati ons when chall enged by anti -vacc ine me sage. ? qualitati e
study. Va c ine 24,7238 -7245 . do i: 10. 10 l6/j .vaccine .2006 .05 .0 10
Levi , B. H. (2007) . Addre ing parent ' concern about childho d immuni zati n
tutori al for primary care prov ider . Pedia trics 120( 1), 1 -26.
doi: 10.1542/ped .2006-2627
Lin k- ell e , R., hamberlin, A. T., chulkin , J., Ault, K., Whitn y, ., eib, K.,
. B. (20 l 2). Mi s ed opportunitie : nati onal urvey f b tetri cian ab ut

m r,

90
attitud
n mat mal and infant immunizati n. Maternal and hild H alth J ournal,
16() 174 - 1747. d 1:10.1007/ 109 5-01 1-09 6-0
.,

ingh M. . (20 1 ). riti a! readin g
. L B i nd -W d J. Harb r
arch in anada : Meth od , criti a /

Lu ten J.,
rga li , ., 11 n
Beutel , P. (201 ). Ki kin g again t th e
ial ri entati n. E uropean J ourna l of
pri k
ac ine ce ptic ha e a different
P ub lic Health , 24(2 , 3 I 0-3 14. d i: 10. I 09 /eurpub/cktO 0

L ren,
a

L nard . (20 ). a cine refu al: 1 ue [! r th primary care ph y i 1an.
finica l P ediatri , . 45(5), 99-404. d i: I 0. 11 77/000 22 062 58 I

nald ,
in Ia , J. . (20 I ). W rk ing with vacc ine-he itant par nt .
hild !iealth , 1 (5), 2 5-267 . Retri eved fr m
Paediatrics
d cument /p iti n/w rkin g-w ith - a cin -he itant-parent
http ://w w.cp

Maki ,

Bart n, . (20 14, March 2 ). ea le outbreak rai e qu e ti n ab ut
r i tance to vacci nati n. The lobe and Mail. Retri eved fr m
http: //www. th globcandm ail. com

McMun·ay, R., heater, . M., Weighall , ., el n ., chwe iger, M., & Mukh erje ,
(2004) . Manag in g c ntr ve r y through co n ultati on: qu alitati ve tudy f
c mmunica ti on and tru t around MMR vacc inati n dcc i i n . British J ournal qf
General Pra rice 54(504), 520-525 .
Mergler, M. J., Orner, . B. Pan, W. K. Y., avar-Boggan, A., ren tein , W ., Marcu e,
. J., .. . alm on, D. A. (20 13 ).
oc iati on f vacc in e-related attitu de and bel ief
betwee n parent and hea lth care provi der . Vaccin e, 31(4 1), 459 1-4595 .
doi: 10.10 16/j .vacc in e.20 I 3.07 .039
Mnookin , . (20 I 2). The panic virus: The true story behind the vaccine-all/ ism
controversy. New York, Y: imon & chu ter.
ati onal Vacc ine Info rmati on enter. (n.d.). Intern atio nal memorial for vacci ne victim
Retrieved from http ://www .nvic .org accine-Memori al. a px
ield , L. . (2008) . Anti -vaccine media : It impac t and trategie to combat it [ pecia l
issue]. Consultan t for P ed iatricians, 7(9), s4- 7.
ffi t, P. A., Quarl e , J., Gerb er, M. A., Hackett, . J., Marcu e, E. K., Kollma n, T. R., ...
Landry, S. (2002). Addres in g parent ' concern : Do multipl e vaccine
ef\vh lm
or weaken the infant's immune sy tem? Pediatric 109( 1), 124- 129.
doi: 10. 1542/peds .109. 1. 124
mer, S. B., a lm on, D. ., ren tein , W. A., deHati, P., & Hal ey, . (2009) . Va
refu sa l, mand atory immuni za tio n, and th e ri k of vacci n -pre en tab le di
TheN w England J ournal of Medicine, 360. 198 1- 19 . Retrieved from
http ://www. nejm.org/

me

91
. J. R bin n, J. ., Heritag J. , K rfiati , . Tayl r, J. ., Mangi ne- mith,
R. (20 12). hara teri zin g pr ider ' immuni zati n c mmuni ati n pra tic during
h alth upervi i n i it with a cin -h itant par nt : A pil t tudy. Va cin e 30(7).
126 - 1275 . d i:l0 .101 6/j . a ine.201J .12. 129
pel,

. J. Heritag J ., Ta I r, J. ., Mangi ne- mith R. ala , 1-1 . ., D Ver , V., ...
R bin n, J. . (20 1 ). The archite ture f pr ider-parent vaccin di cu ion at
hea lth up er i i n i it . Pediatrics 132(6), 10 7- 1046 . d i: I 0.1542/ped .201 -20

Pell y,

. P. Pien yn w ki Mac uga ll , . M., llalp rin , B . ., trang, R. A ., B wle ,
K ., a end ale, . M., Me eil ,
. (20 J0) . TH V
PR J
: An
ment f immunizati n du ati n in anadi an h alth pr fe
na l program .
Medical Education, 10, - 4. d i: 10.11 86/ 14 72-6920- 10- 6

t ber 2 1). Helpin g parent
rt vaccina ti on fact fr m myth . Th e
Pea r , T. (20 I ,
lobe and Mail. R tri e ed fr m http ://www .th egl beandmail. m
Pet u i -llaiTi H. o d ear- mith, ., Tu mer, ., & e, . (2004 ). Family phy ician
per pecti e on barrier t chi ldh d immunizati n. Va cine 22, 2 40-2 44 .
doi : IO: l 0 l 6/j. ac ine.200 . 10. 7
Pr

incial H alth ervice
uth rity. (20 12) . infan t immunizations . Retri eved from
http ://www .immuni z bc.ca/ge t acci nat d/i nfant-imm uni za ti on

Publi c H alth gency f anada . (2006) . anada ommunicahle Disease Report.
upplemenl: anadian arional Report on Jm muni::.arion, 2006 . 2 3. J
J 1884 149 . R trieved fr m http ://www .pha -a pc.gc.ca/publi at/ccdrJTI1tc/06v 132/ 2 Ii nde -eng.php
Public Health gency of anada . (20 13a). anadian Jmmunizarion Guide: Part 1. K ey
immuni::.ation informal ion 2013 . Retri eved from http ://www.p haca pc.gc.ca/pub li cat/cig-gci/pO 1-eng.php
Public Health Agency of anada . (2013b) . Srrategic risk communicarionframework
vvith in the context of H ealth anada and rh e PHA 's integrated risk managemen f.
Retri eved from http ://www .phac-aspc.gc .ca/publicat/2007/ri k-com/ indexeng .php#a I
Reich, J. . (20 14 ). eo liberal mothering and vacci ne refu al : Imagined ga ted
communities and the privilege of choice. Gender & Society, 2 (5), 679-704 .
doi : 10.11 77/089 12432 145327 11
Rey na, V. F. (20 12) . Ri k perception and communica ti on in vacci nation deci ion :
fuzzy-trace theory ap proach. Vaccine, 30(25), 3790-3 797 .
doi : 10.10 16/j. vaccine.20 11 .11 .070
Rourke, L. , Leduc, 0 ., & Rou rke, J. (20 14) . Rourke baby record:
infant/child hea lth maintenance . Retrieved from
http ://www .rourkebabyrecord .ca/walk l .a p

idence-ba ed

y temati
adaf, A., Ri chard s, J. L. , lanz, J. , almon, D. A., & Omer, . B. (20 I ).
rev iew of interventi ons for reduci ng parental vacci n refu al and vaccine he itan
Vacc ine, 31(40), 4293-4304. doi : IO .JOI 6/j .vac ine .2013 .07 .0 1

92

aint-Vi t r, . . & m r, . B. (201 ). Va cine refu a! and th ndgame: Walking the
Ia t mile fir t. Philo ophi a/ Tran a tion of the R oyal oci ty of London. erie B,
Biologi a/ 1en es, 36 (162 ) 2012014 . doi :l0 .109 /r tb .201 2.014
aitoh, A., Nagata
ait h A. T ukahara, Y., Vaida, F., on b , T., ... Murashima,
(20 1 ). Perinatal immunizati n education improv immuni za ti n rate and
knowledg : rand mi zed contr II d trial. Preventive Medi ine, 56, 398-405 .
almon , D. ., M ult n, L. H., mer, . B., D hart, M. P., tokl ey . & Hal y, N. A.
(2005) . Factor a ociated with refu a! f childho d vaccine am ng parent of
ch !-aged hildren: ca e-c ntr I tudy. Archive of Pediatric Adolescent
Medicine, 159, 4 70-6 .
anitz, . (2012) . A urvey of nur e practiti ner practice
ang ter- ormley, ~.,
patt rn in Briti h
lumbia. Unh rsity of Vi tori a chao/ of ur in . Retrieved
fr m http ://www .u ic.ca/h d/ nur ing/a et /doc /new /np ra ti c
att rn .pdf
h !by, ., & - m t, K . (20 13). t ry and cience : H w pr ider and par nt can utili ze
t ryt Iling t c mbat anti - acci ne mi in~ rmati n. Human Vaccin e &
imm unotherap eutic 9( ), 1795- 1 01. d i: I 0.4161/hv.24828
mith, P. J., Ken n dy, . M., Wooten , K., u t, D. A., & Pi ckerin g, L. K. (2006) .
A ociati on b tween healthcare pr vid r ' influence on parents who have concern
about accine afety and accine coverag . Pedia trics, 1 18(5) , e l 287-e l 292 .
doi: 10. 1542/ped .2006-0923
mith, P. J., hu, . Y., & Barker, L. . (2004) . hildren who hav received n vacc mes:
Who are they and where do they live . Pedia trics, JJ 4(1 ), 187- 195 .
turm L.A., May , R. M., & Zimet, G. D. (2005) . Parental belief and deci ion mak in g
abou t child and ado lescent immunizati n: from polio t exua ll y tran mitted
inti ction . Journal of D evelopm ental and Behavioral Pediatrics, 26(6) , 44 1-452 .
uk, J. E. (20 10) . Vaccine afety : Mi informed abou t the mi sinformed . Th e Lancet
lnfectiousDisea es, 10(3) , 144 .
Vaccination Informatio n etwork. (n.d.). ategory archive : Adverse events. Retri eved
from http ://www .vacci nati oninfoJmatio nnetwork.com/category/adverse-events/
Vaccination Risk Aware ness Network. (n .d.). Health risks . Retrieved from
http ://vran .org/hea lth-ri sks/
Vaccine safety : lnfom1ing the mi infOJmed . (2009) Th e Lancet l nfechous Di ea es, 9( 12),
719.
Vannice, K . S., Salmon, D. A., Shui , 1. , Orner, S. B., Ki ner, J. , Edwards, K. M., ...
Gust, D. A . (20 11 ). Attitudes and belief of parents concern ed about vaccin :
Impact of timing of immunization information . P edia trics, 12 7, 120-s 126. doi :
10.1542/peds.20 10-1722R
Walkinshaw, . (20 11 ). Mandatory vacci nation : The Canadian picture. Canadian
Medical Asso iation Journal, 183( 16), e ll 65-e l1 66 . doi : J 0.150 I maj .l 09- 992

93
Whitt m r , R. Knafl , K. (2005 . Th int grati r Jew :
Journal of Advan d ur in , 2(5) , 54 -553 .

pdated m

Wil

ping with anti- a ination 2. 0. '" anadian
n K. (200 ,
mp ium c nduct d at th 111 ting f th Publi
immunization
H alth gency f anada
r nto , ntari . Retri ved fr m http ://www .qa .phaca pc.gc.ca/cnic- ni/200 /pre li nd -eng.php

W If

. R., pel, ., eHart, M. P., Warren, J. , R whani-Rahb ar, A. (20 14). Impact
f a pertu
epidemic n infant a cin ati n in Wa hin gt n tat . P diatri s.
134( ) 45 -464 .

d-Harp er, J. (200 5 . Jnfom1in g edu ati n p Iicy n MMR: a lancin g indi vidu al
freed 111 and c ll ective re p 11 ibiliti c £1 r th e pr m ti 11 [ publi hea lth . ursing
Eth ics, I ( 1), 4 - . d i: I 0.11 1/09697 00 5nc757 a
W

dwa rd J. (2 01 4).
va cin ati n rate dr p amid ' mi infl rm ati n ampaign. TV
anc uv r. Retri eved fr m http ://bc .et new .ca/b-c- acc i11ati n-rate -dr p-amidmi inform ati n-ca mpaign- I . 1744 7

Zuni ga d

u11 i , M. L. , ader, P. R., awye r, M. ll. , De uire, M., Pri lin, R.,
lder,
J. P. (2 00 ). pr natal interv nti n tud y t impr e tim elin e immuni za ti n
initi ati on in Latin o infant . Jo umal qf ommunity Health 28(2), 15 I - 165.

94
APPEN DI X A
Thi table f e id nee rat
typ and trength [ ea h tudy (

re earch arti le
Bi nd -

na

al

f l - 7 d p nding n the

d Haber, am r n, &

ingh, 201 2).

Le el 1: y tematic re i w r meta-analy i f rand mi zed c ntr II d trial
(R T ); evid n ee- in~ rmed clini a! pra tic guid lin ba d n
y temati r iew .
Le

I 2:

Le el 3:

well-de igned R T.
ntroll cd tri al without rand mi za ti n (qua i-e perimental tudy) .

Le el 4 : ingle n n-e ' peri mental tudi e - a -c ntr I, c rr lati nal ,
tudi .
Leve l 5 :

Table

tema t1 c re 1e

f d cripti e and qualitativ

Le el 6:

ingle de ripti e r qualitative tudy.

Le el 7:

pini n f auth ori ti e and/ r report

h rt

tudi e .

f c pert committee .

lnte rath ·e re1·iew e\•idence

Leve l of
e id ence
lanz et al.
(20 1 )

4

Hendri x,
Finnell ,
Zimet,
tutm,
Lane, &
Down
(20 14)

2

Kaufman
et al.
(20 13)

Popul ation and
fo cu

children <4 yea r of
age
To de crib e parental
vacc ine making
behavi ur and tru t
in pr vider

To detetmine if
em phasizi ng
benefits of MMR
directly to the child
or to oc iety
impacts parent '
vacci ne int nti on
for th ei r infant
Au trali a
( ochrane
Rev iew)

the effect
of face-to-face
intervention for

tud y findin g

ampl e

Interve nti n t
add re parental
vacc1ne
2nd pha e:
concem may b 854
more effec ti ve if
th ey are app li ed
earl y (duri ng
pregnancy) and
ften
(p regnancy to
infancy)
Hea lthcare
provider hould
em pha ize
MMR benefit
to the child

02
parent

The limited

6R T
and 1

95

ac inati n n
immuni za ti n
uptake and parental
kn wl dge

Kempe et

4

a l. (2 0ll)

Paedi atri ian and
famil y ph y JCJan
( I )To a e

th e
preva lcnce [
parental requ e t to
dev iate fr m
acc 1ne chedul e
(2) re p n e to

uch reque t
( ) attitud ab ut
th burden and
ucce of vacc ine
communi ca ti n with
parent
L a k,
Chapman,
Hawe, &
Burge

K

Burden f
c mmuni catin g
with parent
ab ut va me
I hi gh.
Phy ician
report grea te
with
c n mcmg
ce pti ca l parent
u mg me age
ab ut th eir wn
per onal cho ice
and ex p ri ence

R T

(

6

Moth er of yo un g
children
xpl ore how
parent re pond to
competin g medi a
me ages about
vacc me afety

Per onal
ex p n nee ,
va lue ystem ,
and leve l of
tru t in hea lth
profes ional
are fun da mental
to dec i io nmaking. tori e
of peo pl e
affected by
vacc mepreventabl e
di ea e need to

36 moth er

6

Parent of children
age 4-5 year
Primary ca re
practitioner ,
manager , and
immunizatio n

Vacc inati on
m age 111
pnmary are are
failin g to get
thr ugh becau e
th e informati on

69

(2 00 6)

McMurray,
hea ter,
Weighall ,
Nel on,
chweiger,
&

quality and
ugg t that
fac - t -fac e
intervention t
in£ rm par nt
ab ut
vaccinati n
ha e littl e r n
impa t n
immuni ati n
tatu r
kn owl edge f

interview
wi th
pa rent
12

intervi v

96
Muk.hetje
(2004)

Opel et a l.
(2 01 3)

To explore par nt
account of
deci ion-m akin g
r lating to MMR
vaccine c ntr ver y
id ntify uptak
detenninant and
edu ca ti on needs

6

Patient
paedi atri cian and
p
To charac teri ze
provi der-pati ent
vacc me
co mmuni ca ti on and
determine th e
influence f pecifi c
provider
communi ca tion
prac tice on parent
resistance to vaccine
recomm endati on

provided doe
not take in t
account parent '
pre-exi tin g
experi ence and
und er tanding.

clinic

R elation of
m dical
research using
vi u al imagery
and ca e tudi e
t provide
v1ca n u
experi ence of
c mmuni cable
di ea e
How provider
initia te th
vaccme
di cus ion is an
important
dete1minant o f
parent re i tance
Wh en providers
pur ue th eir
ori ginal vacc in e
reco mme nd ati on
in th e face of
re is tance, m any
parent wi ll
re lent and agree
to vacc in ate .

111
vacc me
di cu I On
with 16
providers
from 9
practi ces

97

adaf et al.
(2 0 1 )

aitoh et

A
y tematic
review

1

y tematic r view
f data on the
ffecti enes of
int 1 ntions to
addre par ntal
a cine r fu al and
h itan y

Limited
vidence to
guide
imp lementati n
of effecti e
tra tegie .
eed for
appropriately
de igned,
xecuted and
evaluat d
interven ti n
tudie to
addre the gap
in knowledge

30 tudie

Japan

2

Pregnant wo men
To determ in e if
perin atal
immuni za ti on
edu ca tion increa
vaccine uptake in
infants

Perin atal
immuni za ti n
education
improved
immunizati n
tatus of infants,
m rea d
w men'
knowledge on
immuni zati on
and intenti on to
vaccinate
infants

119

al. (201 3)

Va nni ce et
al. (20 11 )

USA

3

Mothers who
Di tribution of
indi cated concerns
vacc me
about infant
in fonnati on
vacc mes
significantly
improved
To determin e if
attitudes
g1vmg vacc me
regardless
of the
info nnation
materi als before the visit th ey were
2-month vaccination provided.
v isit to mothers with All owing
adequate time to
concerns about
.
.
review vaccme
vaccine safety
info rmation may
positi vely changed
benefi t
their attitudes and
concerned
beliefs about
mothers
vacc ine safety

pregnant
moth rs

272

mother

98
APPENDIX B
Historic

olitical and socio-cul t ural context

Health
profess ionals'
reco mm endanons

Pu bl ic health and
vacc me pollc1es
•Vaccmanon
programs
• f>romo on &
commun1ca on
• Sa fety cvaluallol
and mon1 tor ng

lnd1v1dual Dec1S10n -Makmg
about vacc1na on
Acceptance

Hesit ancy

Commun1cat1on and med1a
• l•ddlt on.J IY!cdla/lnte ne & Soc al m£>dld
• Ar 1 vacc1nat on ac Y>ts

Figure A Conceptual model consist in[!. qfthree domains qffacton that interact and mcz\ '
lead to vaccine hesitancT at the indh ·idzwlle1'el.
Thi model depict vaccine he itan 1 a an individual b haviour, influenced b; decisionmaking that i haped by a range of different factor . The e factor range fr m
individualized characteri tic , such a kno'v\ ledge and moral conviction . t broader
factors. such a hi toric, politicaL and ocio-cultural influences. Adapted from
"Conceptual model of vaccine hes itanc) ... b) E. Dube. . Laberge, M. Gua), P. Bramadat
R. Roy, and J. A. Bettinger, (20 13), Human I 'accines & Jmmunotherapeutics . 9(8).
p. 1764.

,

99
PPENDIX
ab l 4 ~anadian immunization Guide:

afional Guidelines for Immuni:::ation Practi es,
, el cted 'uidelines Rele l'anllo Va cine Hesitancy

Guideline 4
immuni zati on u ing an

rnmuni cate current kn wl edg ab ut
id en -b
d appr ach.

a cin pr id r h uld edu cate peopl e in a ulturall y
pr f rabl in their v n language, ab ut the:
imp rtanc of

c inati o n,

di

i ne pre ent ,

r

mm ended immuni zati n

n iti ve w ay,

hedul e

need to rece i e vac i nes at reco mme nded age , and
1111p rtan e f rin gin g the imrnuni zati n record t eve ry health

Guideline 5

Guideline 6

hould rec omm end deferra l or vv ithh ldin g o f
nl y.

100
APPENDIX D

Child-C.ntf•d Communication
(Hend ri x et al., 2 0 141

Preaumptive va. Participatory Communication
(O pel et al., 20 13 )

Communication Content

c:

Na"ative-Baaed Vaccine Communication

0

V)

0
u

·-....0c:

(McMurray er ol., 20041 Ke mpe et ol., 20111 Leask,
O.apmon, Howe, & Burgess, 2006)

·.;: c

·-c::>

(J)

>

E (J)
E +c:
~

Prenatal Vaccine Communication

Communication Timing

(Glanz et oL, 20 13; Soitoh et al., 201 l1 Vannice et
al., 20 1 1)

0

u

Lack of Evidence to
Support Communication
Interventions

~Kallfman et a l. 201 3; Sadof e

al. 20 13)

igure B Thematic analys is of the litera/w-e re\'i<!ll' finding.\ .
Thi fi gure depi ct th e th eme. deri ved from th e findin gs o f th e literature re iew a rti c l e~.
A ll I 0 ource id entifi d c mmuni ca ti on interve nti ons a. th e ove rarchin g th eme. From
thi , three fUJ1h er th eme \\ ere identifi ed: c mmuni ati on c ntent, c mmuni cati on timin g,
and a lac k o f e id en e t upport c mmuni cati on interventi ons. T he th eme o f
co mmuni cati on content and timin g includ ed f our ubth emes th at identifi ed w hat
trateg ie co uld b uti lized w hen addre in g vacc in e hes itanc; m pnm ar; care.