Parental refusal or delay of childhood immunization: Implications for nursing and health education

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Abstract

The purpose of this article is to review the current literature to ascertain reasons behind parental refusal or delay of childhood immunizations. Recurring themes highlighted issues involving parents and health care providers. Strategies to improve immunization compliance were proposed. Health care professionals and health educators were identified as instrumental in the effort to educate and positively influence immunization. As one of the most highly trusted members of the health care team, a nurse is vital to the success of this endeavor.

Introduction

In the early 20th century, more than 1 million children in the United States contracted communicable diseases each year. Approximately 5–10% of those children died or suffered chronic disability or disease. However, since the implementation of immunization programs, the incidence of communicable childhood diseases in the United States has significantly declined (Centers for Disease Control and Prevention [CDC], 2000). The concept of vaccinations actually originated in India before 1000 A.D. In 1796, Edward Jenner developed the smallpox vaccine, which was used for compulsory vaccinations in Europe (Calandrillo, 2004). Immunizations in the United States began in Massachusetts in 1809. By the mid-1900s, federal laws were enacted to provide immunization funding and mandatory state laws began in the 1960s (Calandrillo, 2004). Today, many common diseases like polio and smallpox have been completely eradicated in the United States. Unfortunately, there are still approximately 85,000 cases per year of vaccine-preventable diseases (CDC, 2003).

Immunizations provide a means of preventing certain diseases, not only for the people who are vaccinated but also for those who cannot be vaccinated but may be exposed to disease. This concept, herd immunity, means that immunized people prevent the spread of disease to unimmunized people (CDC, 2006a). However, for this immunity to be effective, 80–95% of the community must be immune depending on the virility of the disease (Malone & Hinman, 2003, National Network for Immunization Information, 2005a). Additionally, many of the communicable diseases that have been eradicated or contained in the United States are still prevalent in other parts of the world. The frequency and ease of international travel and adoption in today's world make exposure to vaccine-preventable diseases highly likely (Centers for Disease Control and Prevention, 2000, King County Public Health, 2006). According to the CDC (2003), if immunizations were to stop, vaccine-preventable diseases would return to prevaccine levels with more deaths annually. Deaths from measles alone would exceed 2 million per year, worldwide (CDC, 2003).

While failure to immunize poses a public health threat, delayed immunizations are equally detrimental. Delayed vaccine delivery extends a child's vulnerability to preventable diseases, places a child at unnecessary risk, and exposes others by providing opportunities for diseases to spread (Children's Vaccine Program, n.d., Glauber, 2003). The standard vaccination schedule, jointly published by the American Academy of Pediatricians, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians, recommends the 4:3:1:3:3:1 series (see Table 1) to guard against 12 vaccine-preventable diseases (Centers for Disease Control and Prevention, 2006b, Darling et al., 2006). According to Darling et al., 2006, evaluations of up-to-date status are based on this standard schedule.

In 2005, the national up-to-date immunization coverage rate was 76.1% for children 9–35 months (Darling et al., 2006). Children in kindergarten through first grade, during the 2005–2006 school year, had immunization rates in the 90% range (Stanwyck, Davila, Lyons, & Knighton, 2006). Thus, refusal and delay rates ranged from approximately 10% to 25%. While these vaccination rates are at an all-time high, Healthy People 2010 seeks immunization rates of the 4:3:1:3:3:1 series for the 19- to 35-month and the 4- to 6-year age groups of greater than 80% and 95%, respectively (Darling et al., 2006, Stanwyck et al., 2006, U.S. Department of Health and Human Services, n.d.).

Healthy People 2010 goals are at risk for not being met, and the security of communicable disease containment in the United States is threatened by a growing trend of parents refusing or delaying immunization for their children, along with inconsistent immunization laws (Fredrickson et al., 2004, Malone & Hinman, 2003). Studies indicate growing parental concerns and uncertainty regarding the safety of childhood vaccines (Fredrickson et al., 2004). A large number of antivaccination media, action groups, and web sites further complicate the situation by publicizing negative vaccine information and highlighting reasons for concern that often have no scientific support. More than half of U.S. family practice physicians encounter parents who refuse to immunize their children, whereas as many as 93% of pediatricians report that parents have refused (Garcia, 2005, Lyren & Leonard, 2006). This trend of refusals and delays has made the threat of outbreaks more likely to occur today than a decade ago. A reappearance of disease outbreaks is a signal that the immunization status in the United States is in jeopardy (American Nurses Association [ANA], 1997). The occurrence of pertussis and measles has continually increased since the 1980s. In fact, measles, rubella, and pertussis have had outbreaks as recently as 2005. These outbreaks were primarily caused by diseases originating in other countries and infecting unimmunized individuals or individuals whose immunizations were not up-to-date (Centers for Disease Control and Prevention, n.d., King County Public Health, 2006, Parker et al., 2006).

In an era where child safety is a prominent focus, why would parents risk the threat of preventable diseases by refusing to properly vaccinate their children? Calandrillo (2004) pointed out that recent outbreaks have not attracted attention because the eradication of diseases has eliminated the threat of susceptibility, thus resulting in complacency toward immunizations. In other words, because of immunizations, people in the United States do not get polio anymore; therefore, some parents do not see the need to immunize their children against it, not realizing that the disease can be easily transported and can recur without continued immunizations. Similarly, many people view measles, mumps, varicella, and other communicable diseases as benign and as part of childhood. Unfortunately, they are uninformed of the fact that these diseases often lead to long-term sequelae and can kill 1–5% of infected individuals (King County Public Health, 2003). Research has identified other reasons why parents refuse immunizations, including fear of immunization safety and side effects, lack of knowledge about schedules, inaccessibility and cost, and religious beliefs (Fredrickson et al., 2004). Health care professional factors like lack of knowledge, fear of vaccine safety, and inadequate parent counseling also contribute to immunization refusals and delays (Baltrun, 1999, Bichler, 1997). Finally, variations in mandated vaccination laws and exemption provisions allow for easy avoidance of proper immunization practices (Fredrickson et al., 2004).

Today, with an increase in immunization refusals or delays and the threat of bioterrorism, the welfare of public health is jeopardized. Efforts to educate and positively influence immunization dissentors are necessary. In addition, other strategies are also necessary to increase the timely immunization status of children in America. The purpose of this article is to review the current literature to ascertain reasons behind parental refusal or delay of childhood immunizations. This review should make nurses and other health care professionals aware of the issues and the roles they play in ensuring the safety of the public health. Gaps and inconsistencies in current practice will be identified and strategies for future action will be proposed.

Section snippets

Review of the literature

Underimmunization of preschool children continues to be a serious public health threat despite extensive efforts to assess and monitor national immunization rates by the CDC (Baltrun, 1999, Bichler, 1997, Busby, 1999). A CDC study in 1991 found that only 4 in 10 children in cities included in the study were properly immunized by the age of 2 years (Bichler, 1997). Multiple studies determined that parental factors and behavioral strategies that may have influenced the compliance rates included

Gaps, contradictions, and inconsistencies

Vaccination laws in the United States are governed by the individual states. This fuels the controversy allowing for inconsistencies in the immunization laws and the exemption process. The federal government supports mass immunization by providing funding and resources to the states. All 50 states currently require immunization prior to a child's entry into school; however, the exact vaccines and doses vary from state to state. Every state allows parents to refuse vaccinations by claiming

Implications

It is imperative that health care practitioners, and nurses in particular, close the gaps as dictated by Healthy People 2010 (U.S. Department of Health and Human Services, n.d.). Trust in health care professionals is enhanced when similar information about the prevention of communicable diseases is provided. Salmon et al. (2004) noted that the training, knowledge, attitudes, and beliefs of school personnel involved in working with parents on immunization issues were associated with the

Strategies

One of the issues to address from an educational point of view is how to combine the efforts of the various health disciplines to move the current immunization rate from the mid 70% to greater than 90%. (Darling et al., 2006, Stanwyck et al., 2006, U.S. Department of Health and Human Services, n.d.). As one of the most highly trusted members of the health care team, a nurse's role is crucial to the success of these efforts (Johnson, 2002, Jones, 2005). The ANA (1997) encouraged its members to

Conclusion

There is no dispute that vaccine-preventable diseases are at an all-time low because of high immunization rates and compulsory vaccination laws. However, the growing trend of parents refusing or delaying childhood immunizations is threatening our nation's public health (Fredrickson et al., 2004). In order to preserve containment of communicable diseases, strategies are needed to increase childhood immunizations. Literature reveals that there are both parental and health care professional

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