A qualitative interview study with parents to identify barriers and drivers to childhood vaccination and inform public health interventions

Figures & data

Table 1. Participant characteristics

		Urban PCC	Rural PCC	Total
Parental status	Mother	12	7	19
	Father	2	1	3
Number of children	1	4	2	6
	2	8	4	12
	3	2	2	4
Child’s vaccination status	Fully vaccinated	4	2	6
	Delayed/Partially	5	4	9
	Unvaccinated	5	2	7

Note: Child is child in patient file study. Fully vaccinated: Received BCG vaccine, three doses of any DTP-containing vaccine (3-valent DTwP, 4-valent DTaP-IPV, 5-valent DTaP-IPV-Hib), three doses of hepatitis B vaccine, three doses of polio and first dose of the MMR vaccine. Delayed/partially vaccinated: Received some (either on time or delayed), but not all (available) recommended vaccines (e.g. BCG, hep B1, and DTP1, but no DTP3 or MMR). Unvaccinated: Never been vaccinated or who just received BCG and hep B at birth.

Table 2. Illustrative quotes for individual factors: capability and motivation¹⁷⁻¹⁹

COM factor	Theme	Quote ID	Participant ID and quote
Capability	Knowledge of vaccination and vaccine-preventable diseases	C1	“It’s [measles] not that serious. Lately, we have measles cases every now and then, and the deaths, generally those were people with compromised immunity. So, people with well-built immunity, they don’t die from measles. We have managed to build a good immunity system for our child.“ (U_VS_OV3: urban, unvaccinated)
	Planning and organizing vaccination	C2	“I’d get them [child’s vaccinations] following my own initiative. I call the health center and ask them when I can bring my child.” (U_AK_DV1: urban, delayed/partially vaccinated)
		C3	“We took a picture in the health center of how it works by month, and so we brought her.” (U_VS_DV1: urban, delayed/partially vaccinated)
		C4	“Essentially, the reason of his non-vaccination, and of the daughter as well, is the lack of time and poor organization. It was unintentional, no time, organization, little consideration.” (U_AK_DV2: urban, delayed/partially vaccinated)
Motivation	Attitudes and risk perceptions	M1	“If you don’t vaccinate, I think the risk of catching a disease is a bit higher than for children who are vaccinated, and that’s why, essentially, I want the best for my child, and that’s why I vaccinate them.” (U_SM_PV5: urban, fully vaccinated)
		M2	“The child is not prone to illness at all. We’ve managed to build a good immune system for him, and we think that with less introduction of chemical things in his body we’ve made it easier for him to build his immunity.” (U_VS_OV3: urban, unvaccinated)
		M3	“You inject a virus into a small child who is yet to build its defense system. So, the idea is to inject five viruses into my child at the same time and hope that he copes with it. Some children suffer consequences from those vaccines. I don’t want to let my child, to expose my child to all those viruses at the same time. I am not informed but simply it’s common sense.” (U_VS_OV4: urban, unvaccinated)
		M4	“Well, I’d vaccinate if I knew it is administered in other countries, and then I would know that it’s already [being used] somewhere, that it’s been studied. I don’t think they administer vaccines that haven’t been studied.” (R_MS_DV1: rural, delayed/partially vaccinated)
		M5	“Vaccines are procured through public procurement. They make a specification on the basis of which they procure a vaccine, meaning to say, every specification includes certain criteria, of what it should be like, what it must contain and certain producers, meaning to say it should be detailed.” (U_SM_DV2: urban, delayed/partially vaccinated)
		M6	“I got some information that here these vaccines are not stored as they should be, like in cold, like, in a little box as it happens, like, abroad. For example, today we have fifteen children scheduled, they take from the storage room that isn’t cold, not a refrigerator, they take out these vaccines, put in the fridge, and vaccinate our children. When you hear all these stories, you wonder.” (U_VS_DV1: urban, delayed/partially vaccinated)
		M7	“I don’t oppose vaccination of children. Regarding the [MMR] vaccine, my child wasn’t vaccinated for the reason that since she started kindergarten, she constantly has some colds and her nose is running and whenever I go to see the doctor, no one dared to administer that vaccine or any other vaccine.” (U_VS_DV1: urban, delayed/partially vaccinated)
		M8	“We didn’t want to vaccinate with the MMR because of the media propaganda. Well, the parents speak out because their children got autism, they stopped talking. Like all vaccines, when children get them, the brain gets, like, how shall I put it, swells a bit, and from this vaccine most, and that may be the reason and trigger of something, these children, well, they have consequences after receiving this vaccine.” (U_VS_OV1: urban, unvaccinated)
	Confidence and trust	M9	“[I trust] the pediatrician when it comes to my child’s health. I most believe it there because of the level of expertise.” (R_MS_DV1: rural, delayed/partially vaccinated)
		M10	“I don’t trust our pediatricians, specifically ours, at our health center. They had no answer to some questions we asked, not about vaccines or they gave an incorrect answer. Somehow sometimes I have a feeling that I know some things better than they do.” (R_MS_OV2: rural, unvaccinated)

Table 3. Illustrative quotes for context factors: physical and social opportunity¹⁷⁻¹⁹

COM factor	Theme	Quote ID	Participant ID and quote
Physical Opportunity	Access	PO1	“I need to pay for the ride to take my children there, I have no other costs, but of course I come.“ (R_MS_PV1: rural, fully vaccinated)
		PO2	“So far, it’s never happened they don’t have a vaccine, meaning to say, I trust they have them.” (R_MS_DV1: rural, delayed/partially vaccinated)
		PO3	“Well, there were cases the vaccine was not available, but we arranged it with pediatricians in advance. If they knew there wouldn’t be sufficient stocks, they’d say come in a month and a half or phone us before to check whether it’s available or not, it’s not that we would come to the clinic only to go back without being vaccinated.” (U_AK_PV1: Urban, fully vaccinated)
	Convenience and appeal of vaccination services	PO4	“My child’s health is a priority for me, of course I’ll skip work and all obligations to take him, so that it’s not a barrier for me personally.” (U_AK_PV1: urban, fully vaccinated)
		PO5	“They don’t ask you when you can come, they simply give you the time. And you know how difficult it is here to leave work. What could help me [vaccinate my child] is that, we can go and visit the doctor without an appointment.” (U_VS_OV1: urban, unvaccinated)
		PO6	“This is a children’s ward, so it’s decorated in different colors and drawings. It’s very neat, nice.” (R_MS_PV1: Rural, fully vaccinated)
		PO7	“The situation is very good, at the health center because children who are ill are separated from healthy children, so there are two waiting rooms and I like it very much, and it suits me because it isn’t fair that a child who’s healthy and comes there for a reason like vaccination or simply for any examination or a health certificate should be exposed to bacteria and viruses of the ill children.” (U_VS_PV1: urban, fully vaccinated)
		PO8	“Well, the waiting rooms at the health center aren’t quite adequately structured. Where I used to vaccinate my child, the place had, separate entrances for healthy and ill children, which was in line with protocols, probably. However, in the municipality, the health center (name) that’s not the case, so I’m not happy. Healthy and ill children are mixed when we get there for vaccination.” (U_AK_PV2: urban, fully vaccinated)
	Health systems	PO9	“No, never [have I received a reminder]. Every time I come for vaccination, when talking casually and consulting with the pediatrician we agree on a date of the next vaccination, but a reminder of some sort, via E-mail, mobile telephone, no.” (U_AK_PV1: urban, fully vaccinated)
	Legislation	PO10	“Frankly, I’d introduce it [the law] for children who can’t for health reasons [be vaccinated]. For children who are sufficiently healthy and should receive it. There is a large number of unvaccinated children who for no medical reason, who can be vaccinated. I don’t know whether this [law] would deprive someone of the freedom of choice, but believe me, in this case, I think I would [implement it].“ (U_SM_DV1: urban, delayed/partially vaccinated)
		PO11	“No state can, not one man in the world can tell someone what to do with their life. If I didn’t want to vaccinate my child, well, the laws are there to be violated, I would break that, no matter what the law says.” (U_VS_DV1: urban, delayed/partially vaccinated)
	Availability of written information	PO12	“[I want to know] everything, let’s say, the basics. Why should we vaccinate children or not, and what am I administering to my child? What sort of bacteria is it that will awaken her immune system to recognize tomorrow that she wouldn’t fall ill with measles or mumps? And I’d like that someone tell me the components of the vaccine and which component will protect her from something. Also, what harm can come to her. So, I have never received feedback on what I have just told you now.” (U_VS_DV1: urban, delayed/partially vaccinated)
		PO13	“I visit the Internet because there, you can find anything, anything you’re interested in. I always try to find what suits me; meaning to say, the negative views on vaccination, I avoid. I always check who’s posted a blog, who’s written an article, who’s given an interview. I always check it and then some things there must be taken with caution.” (R_MS_DV1: rural, delayed/partially vaccinated)
		PO14	“There are a lot of stories you read about bad experiences. There are a couple of forums, which I follow for pregnant ladies and breastfeeding mothers, well, literally it’s a big paradox in the way people think, and now, if I say I’m going to vaccinate my child, there will be five comments, I’m like this, I’m like that, why vaccinate, then another mother says, I don’t know, I won’t.” (U_SM_DV1: urban, delayed/partially vaccinated)
		PO15	“I know that at one point there was a campaign against vaccinating children, then the media, TV certainly it reached me. It was in the newspapers, and I’m sure sort of fear crept in and thoughts about whether vaccines are safe, what side effects they can bring about, so that all of us certainly, maybe, we are a bit scared and would postpone.” (U_AK_DV2: urban, delayed/partially vaccinated)
Social Opportunity	Social support	SO1	“I was lucky with my son, I had a wonderful pediatrician, and trusted the pediatrician completely and did not think about anything. When she retired, I kept changing pediatricians. I didn’t have anyone who would give me full and true information [about vaccination]. At certain moments I felt they weren’t completely certain in that area, that they didn’t master it, fully, the topic.” (U_AK_DV2: urban, delayed/partially vaccinated)
		SO2	“I talked with the doctor about the MMR vaccine, but of course, doctors aren’t willing to confirm 100% there will be no adverse effects, that it can’t happen. I had no answer from the doctor.” (U_VS_OV1: urban, unvaccinated)
	Social cues, norms and values	SO3	“There have been situations at work, we had a meeting, and then had a coffee afterward and vaccines were mentioned. I said something like my child hasn’t been vaccinated, then the colleagues attacked me, how come, here-there, and then I went silent, simply stopped, I don’t want to, to create a conflict of any sort, so I rarely speak about it.” (U_VS_OV3: urban, unvaccinated)
		SO4	”The ultimate decision is mine and of my husband, meaning to say, no one can assume making this decision for me and can’t influence anything in the sense that they impose something I don’t want.” (U_SM_DV2: urban, delayed/partially vaccinated)
		SO5	“I know a lady said once that, she’s brought her child for vaccination today, and then the next day she ended up in hospital with some major inflammation and the child spent a long time in hospital. It took major efforts to cure him.” (R_MS_PV1: rural, fully vaccinated)

World Health Organization Regional Office for Europe. Tailoring immunization programmes to reach underserved groups – the TIP approach. Copenhagen, Denmark: World Health Organization; 2019 [accessed 12 Nov 2020]. http://www.euro.who.int/tip.

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