Determinants of European parents' decision on the vaccination of their children against measles, mumps and rubella: A systematic review and meta-analysis

Figures & data

Figure 1. Flow diagram of the systematic literature review process on the determinants of European parents' decision of vaccinating their children against measles, mumps and rubella.

Table 1. Studies selected through the systematic review of the underlying determinants of European parents' decision on vaccinating their children against measles, mumps and rubella (MMR).

	Ref. Article	Publication year	Study year	Country	Sample size	Children's age	Data collection method	Administration modality	Administration setting	Vaccine	MMR specific yes/no	Vaccine schedule adherence	Qualitative / Quantitative study
1	Lernout T^6	2014	2012	Belgium	874	18–24 mo	questionnaire	IW	home (face-to-face)	MMR and DTP	yes	partial	quantitative (included in the meta-analysis)
2	Robert E^7	2014	2012	Belgium	519 (in Wallonia); 538 (in Brussels)	18–24 mo	interview	IW	home (face-to-face)	MMR in a schedule^a	no	partial	quantitative (included in the meta-analysis)
3	Harmsen IA^8	2013	2011	The Netherlands	60	0–4 y	focus groups: semistructured protocol with open-ended questions. Digital voice recorded and transcribed verbatim	IW	antroposophical child welfare centers	MMR in a schedule^b	no	NS	qualitative
4	Pavlopoulou ID^9	2013	2010–2011	Greece	731	0–65 mo	interview	IW	home (telephone)	MMR in a schedule^c	no	full and partial	quantitative (included in the meta-analysis)
5	Pearce A^3	2013	2003–2007	UK	751	5 y	interview	IW	home (face-to-face)	MMR	yes	full and partial	quantitative (included in the meta-analysis)
6	van Lier A^10	2013	2009	The Netherlands	180,456	0–14 mo	Country of birth were taken from Præventis (2 October 2009); proxy for SES from The Netherlands Institute for Social Research; proxy of religious objection to vaccination from municipal offices.	NA	official records	MMR in a schedule^d	yes	full	quantitative (included in the meta-analysis)
7	Bouhamam N^11	2012	2009–2010	France	375	9 mo - 7 y	questionnaire	IW	hospital (face-to-face)	MMR in a schedule^e	yes	full	quantitative (included in the meta-analysis)
8	Brown K^12	2012	2008/2009	UK	24	11 mo-3.5 y	interview	IW	home (face-to-face and telephone)	MMR	yes	full and partial	qualitative
9	Kriwy P^13	2012	2001	Germany	464	NS	interview	IW	home (face-to-face)	MMR	yes	full	quantitative
10	Mollema L^14	2012	2006–2007	The Netherlands	1,744	0–10 y	questionnaire	SA	home	MMR in a schedule^f	no	partial	quantitative (included in the meta-analysis)
11	Schönberger K^15	2012	2002–2005	Germany	1,774	< 4 y	interview	IW	home (telephone)	MMR	yes	full and partial	quantitative (included in the meta-analysis)
12	Brown K^16	2011	2008–2010	UK	284	5–18 y	questionnaire	SA	home (postal)	MMR	yes	full	quantitative (included in the meta-analysis)
13	Brown K^17	2011	2009	UK	373	5–18 y	questionnaire	SA	home (postal)	MMR	yes	full and partial	quantitative (included in the meta-analysis)
14	Coniglio MA^18	2011	2008	Italy	1,218	3–5 y	questionnaire	SA	day-care center	MMR in a schedule^g	no	NS	quantitative
15	Sakou I-I^19	2011	2009	Greece	1,005	14 y	questionnaire	IW	hospital (face-to-face)	MMR in a schedule^h	no	full	quantitative (included in the meta-analysis)
16	Babatsikou F^20	2010	NS	Greece	304	0–12 y	questionnaire	SA	day-care centers and primary schools	MMR in a schedule^i	no	NS	quantitative
17	Danis K^21	2010	2006	Greece	2,950	6 y	questionnaire	SA	school	MMR in a schedule^l	no	full	quantitative (included in the meta-analysis)
18	Gardner B^22	2010	2008	UK	28	< 6 y	Focus group discussions informed by a booklet and transcribed verbatim	NA	primary care trust	MMR	yes	NA	qualitative
19	Jessop LJ^23	2010	2001–2004	Ireland	556	5 y	questionnaire	SA	hospital	MMR	yes	partial	quantitative (included in the meta-analysis)
20	Borràs E^24	2009	2003–2004	Spain	630	< 3 y	questionnaire	IW	home (telephone)	MMR in a schedule^m	no	partial	quantitative (included in the meta-analysis)
21	Borràs E^25	2009	2003–2005	Spain	630	< 3 y	questionnaire	IW	home (telephone)	MMR in a schedule^n	no	partial	quantitative (included in the meta-analysis)
22	Pearce A^26	2008	2000–2002	UK	13,826	9 mo - 3 y	interview	IW	home (face-to-face)	MMR	yes	full and partial	quantitative (included in the meta-analysis)
23	Theeten H^27	2009	2005	Belgium	792	7 y	questionnaire	IW	home (face-to-face)	MMR in a schedule^o	yes	full	quantitative (included in the meta-analysis)
24	Vandermeulen C^28	2008	2005	Belgium	3,490	<18 y	questionnaire	IW	home (face-to-face)	MMR	yes	full	qualitative
25	Mixer RE^29	2007	2003	UK	6,444 quantitative study; 37 qualitative study	18 mo - 3 y	For quantitative study: ethnicity data from Brent Primary Care Trust database. For qualitative study: focus groups and interviews transcribed verbatim. A questionnaire on socioeconomic status was filled in	For ethnicity: records. For qualitative study: IW	primary care trust (face-to-face and records)	MMR	yes	partial	quantitative (included in the meta-analysis) and qualitative
26	Smith A^30	2007	1996–2006	UK	1,004	< 36 mo	interview	IW	home (face-to-face)	MMR	yes	NA	qualitative
27	Theeten H^31	2007	2005	Belgium	1,349	18–24 mo	interview and questionnaire	IW	home (face-to-face)	MMR in a schedule^p	yes	partial	quantitative (included in the meta-analysis)
28	Casiday R^32	2006	2004	UK	87	< 4 y	questionnaire	SA	home (postal)	MMR	yes	NS	quantitative
29	Cassell JA^33	2006	2004	UK	413	15–24 mo	questionnaire	SA	home (postal)	MMR	yes	full	quantitative (included in the meta-analysis)
30	Paulussen TG^34	2006	1999	The Netherlands	491	0–4 y and 9–10 y	questionnaire (computer-based)	SA	home	MMR in a schedule^q	no	full	quantitative (included in the meta-analysis)
31	Wright J^35	2006	1993–2004	UK	303	< 2 y	official records	NA	NA	MMR	yes	NS	quantitative
32	Dannetun E^36	2005	2003	Sweden	203	< 4 y	questionnaire	SA	home (telephone)	MMR	yes	NS	qualitative
33	Gellatly J^37	2005	2003–2004	UK	105	1–56 mo	questionnaire	IW	nursery (face-to-face)	MMR	yes	full	quantitative (included in the meta-analysis)
34	Hak E^38	2005	1999	The Netherlands	150	3 mo - 5 y	focus group interview and questionnaire	SA	day-care center	MMR in a schedule^r	no	full	quantitative (included in the meta-analysis)
35	Alfredsson R^39	2004	1999	Sweden	250	< 4 y	questionnaire	SA	home (postal)	MMR	yes	NS	qualitative
36	Flynn M^40	2004	1997–1998	UK	511	2 y	questionnaire	SA	home (postal)	MMR	yes	NS	quantitative (included in the meta-analysis)
37	McMurray R^41	2004	2002–2003	UK	69	4–5 y	interview	IW	home (face-to-face)	MMR	yes	NS	qualitative
38	Petrovic M^42	2003	1997	UK	NA	NA	questionnaire	SA	home (postal)	MMR	yes	full	quantitative (included in the meta-analysis)
39	Smailbegovic MS^43	2003	2000–2001	UK	76	0–18 mo	questionnaire	SA	home	MMR in a schedule^s	yes	NS	qualitative
40	Alonso JAN^44	2002	2000	Spain	NS	NS	questionnaire	SA	home (postal)	MMR in a schedule^t	no	NS	qualitative
41	Ramsay ME^45	2002	2001	UK	1,013	<3 y	interview	IW	home (face-to-face)	MMR	yes	NS	qualitative
42	Evans M^46	2001	NS	UK	48	14 mo-3 y	focus groups with interviews	NA	community hall	MMR	yes	NS	qualitative
43	Swennen B^47	2001	1999	Belgium	1,005 (Flanders), 835 (Wallonia)	18–24 mo	interview	IW	NS	MMR in a schedule^u	no	NS	qualitative
44	Impicciatore P^48	2000	1997	Italy	1,035	<6 y	questionnaire	IW	shopping centers and parks (face-to-face)	MMR	yes	full	quantitative (included in the meta-analysis)
45	Pareek M^49	2000	NS	UK	300	<36 mo	questionnaire	SA	home (postal)	MMR	yes	full	quantitative

^a 4 doses hexavalent, 3 doses pneumococcal, 1 dose MMR,1 dose MenC.

^b MMR, DTP/DTaP, OPV/IPV, Hib, HBV

^c MMR, DTaP-IPV, Hib, Men C

^d polio, DTP, MMR, Hib, MenC, HBV, HPV

^e 2 doses MMR, diphtheria, tetanus, poliomyelitis, Hib, pertussis, tuberculosis, pneumococcal, HBV

^f polio, DTP, MMR, Hib, MenC, HBV, pneumococcal, HPV

^g IPV, DT, HBV, MMR, pertussis, varicella, pneumococcal, Hib

^h The adolescent booster dose (6th dose) Td or Tdap, 5 or more doses polio, 3 or more doses HBV, 2 doses HAV, 2 doses MMR, 1 dose MenC

ⁱ 5 doses DTP, 5 doses polio, 2 doses MMR, 3 doses HBV; MMR available at that time, if they had received 1 dose, at the age of >12 months, and the booster at the age> 10 y; 4 doses Hib if the first dose was administered at the age of 0–6 months and the 4th at the age of > 12 months; alternatively for Hib, 3 doses if vaccination began at the age of 7–11 months and the 3rd dose was administered at the age of > 12 months, or 2 doses if the first dose was administered at the age of 12–14 months or 1 dose if Hib vaccination was administered at the age of > 15 months.

^l 5 doses DTP, 5 doses polio, 2 doses MMR, 3 doses HBV, full vaccination for Hib

^m 4 DTPa/w doses, 4 Hib doses, 4 OPV doses, 3 MenC doses and 1 MMR dose

ⁿ 4 DTP, 4 OPV, 1 MMR, and the necessary doses of Hib and MenC

^o OPV, DTP, HBV, MMR, MenC and booster DT-IPV

^p 4 doses IPV, DTP and Hib, 3 doses HBV and 1 dose MMR and MenC

^q 4 injections of a combined vaccine for diphtheria, tetanus, pertussis and poliomyelitis (DPeTPo), 2 injections with a combined vaccine for diphtheria, tetanus and poliomyelitis (DT-Po), 4 injections with a conjugated vaccine for Hib, 2 injections with a combined MMR vaccine (MuMeR).

^r DPTP, Hib, MMR, MenC, diphtheria, tetanus and polio, a-cellular pertussis

^s BCG, pertussis, polio, Hib, MenC, MMR

^t DTP, OPV, Hib, MMR

^u polio, DTP, Hib, HBV, MMR

Abbreviations

DTP:diphtheria-tetanus-pertussis; DTaP or Tdap: diphtheria-tetanus-acellular pertussis; DT or Td: diphtheriatetanus

MenC: Meningococcus C

OPV/IPV: Oral polio vaccine/Inactivated polio vaccine

Hib: Haemophilus influenzae type b

HBV: hepatitis B

HPV: human papillomavirus

HAV: hepatitis A

BCG: Bacillus Calmette-Guerin

Figure 2. Determinants of European parents' decision on the vaccination of their children against measles, mumps and rubella, reported in the retrieved 45 articles.

Table 2. Characteristics of the retrieved 45 articles on the determinants of European parental decision of vaccinating their children against measles, mumps and rubella (MMR).

Study characteristics	No.	%
Data collection method
• Questionnaires	28	62
• Interviews	12	27
• Focus groups^a	5	11
• Official records	3	7
Administration modality^b
• Interviewer-administered	23	51
• Self-administered	18	40
Data collection setting
• Home	29	64
• Hospital/nursery/primary care trust	6	13
• Day-care centers/Schools	4	9
• Other^c	3	7
Geographical location
• Northern Europe^d	22	49
• Western Europe^e	14	31
• Southern Europe^f	9	20
Questionnaires reporting on
• MMR vaccine alone	31	69
• MMR plus other vaccines included in the local schedule	14	31
MMR vaccine schedule adherence
• All recommended doses	15	33
• 1 dose	8	18
• Both	6	13
Children's age at the moment of the study
• ≤ 5 y	30	67
• > 5 y	3	7
• Mixed age	9	20

^a using semi-structured protocol with open-ended questions, questionnaires or interviews, or discussions, recorded and transcribed

^b delivered by post, by telephone or by hand, or face-to-face interviews

^c anthroposophical child welfare centers, community halls, shopping centers and parks

^d 19 studies in UK, 2 in Sweden, 1 in Ireland

^e 6 studies in Belgium, 5 in The Netherlands, 2 in Germany, 1 in France

^f 4 studies in Greece, 3 in Spain, 2 in Italy

Table 3. Analysis for funnel plot asymmetry of studies reporting the different variables, estimated by Egger's regression test.

	No. studies	coefficient	90% CI	p-value
Knowledge, beliefs, perceptions (right vs misleading)	19	−2.21	−5.560 – 1.178	0.272
Attitudes/behaviors (positive vs negative)	18	−0.83	−3.508 – 1.843	0.595
Ethnicity (different vs local)	31	3.24	0.339 – 6.138	0.068
Socio-economic status (high vs low)	24	2.55	0.825 – 4.268	0.019
Information source/advice (sufficient vs insufficient)	11	6.64	2.140 – 11.137	0.024

Figure 3. Forest plot of the overall effect (showed as exponentiated Odds Ratios and Confidence Intervals) of parental knowledge, beliefs and perceptions (KBP) on measles, mumps and rubella vaccine uptake, examined by KBP on vaccines and on diseases.

Figure 4. Forest plot of the overall effect (showed as exponentiated Odds Ratios and Confidence Intervals) of parental ethnic minority on measles, mumps and rubella vaccine uptake, examined by study geographical location.

Figure 5. Forest plot of the overall effect (showed as exponentiated Odds Ratios and Confidence Intervals) of parental socio-economic status on measles, mumps and rubella vaccine uptake, examined by specific socio-economic determinants.

Figure 6. Forest plot of the overall effect (showed as exponentiated Odds Ratios and Confidence Intervals) of parental information source/advice opinions on measles, mumps and rubella vaccine uptake, examined by administration modality.

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