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| Journal of the New Zealand Medical Association,
20-February-2004, Vol 117 No 1189
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Why do parents choose not to immunise their
children?
Matilda Hamilton, Paul Corwin, Suzanne Gower and Sue
Rogers
New Zealand has very poor rates of immunisation compared
with other countries. Despite the implementation of the National Immunisation
Strategy, with its target of 95% immunisation coverage by the year 2000, there
is little reason to believe that immunisation rates nationally have risen above
the 60% at age two years identified in the 1992 national
survey.1,2 It is estimated that between 3% and
6% of New Zealand parents make a conscious choice not to immunise their children
(personal communication, Dr Nikki Turner, Immunisation Advisory Centre,
University of Auckland, 2003).
There has been little research on the reasons why parents
choose not to immunise their children. A study of 68 parents from a large
English health authority found that religious beliefs and a preference for
homeopathy were the two most common reasons given for not
immunising.3 Another study of parents’
perspectives on the measles, mumps and rubella (MMR) immunisation found that
parents who had chosen not to immunise their children with MMR felt the
potential risks of the vaccine outweighed the risks of contracting the
diseases.4 Another qualitative study from the
UK examined the decision-making process in thirteen parents who had chosen not
to immunise their children and found that parents perceived health professionals
to be providers of unbalanced information regarding
immunisation.5 A recent discussion paper on
immunisation has suggested the need to actively involve the population in
immunisation policy.6 It furthermore suggested
that this change in approach from compliance to concordance requires ongoing
qualitative research into how both immunisers and non-immunisers think. This
study aimed to ascertain the characteristics of parents who have chosen not to
immunise their children, their reasons for making this choice, and their sources
of information.
MethodsPegasus Health is an
independent practitioners association of 230 general practitioners (GPs)
constituting about two thirds of practising family doctors in Christchurch city
(population 318 000), New Zealand. Children registered with Pegasus Health GPs
have a 92.5% immunisation rate at age two years (personal communication, Dr Kim
Burgess, Pegasus Health, Christchurch, 2003). Those GPs who reported to the
immunisation coordinator for Pegasus Health the details of children for whom
immunisation was declined (about one third of all Pegasus members) were asked to
participate in this project. Parents were identified from the Pegasus Health
immunisation database and their own GPs were asked to invite them to take part
in the research. The lead researcher then contacted consenting parents and a
face-to-face interview was arranged. Using a questionnaire to guide the
interview, the researcher sought demographic information about the parent and
details about the child including age, immunisation status and health
professionals the child attended. The researcher asked where parents obtained
information about immunisation and how they rated the quality of that
information. Parents were asked specifically about immunisation information
obtained from health professionals and about their reasons for choosing not to
immunise. The interview took 20–30 minutes to complete. One researcher
conducted all interviews. Ethical approval for the study was granted by the
Canterbury Ethics Committee.
ResultsThe 70 GPs who recorded
‘declined’ children were invited to assist with the research. Thirty
five (50%) GPs agreed to assist, 15 (21%) declined and 20 (29%) did not respond.
Seventy six families registered with the 35 participating GPs who had at least
one child registered as having declined immunisation were invited to take part
in this project. Twenty two (30%) of these parents agreed to take part, 8 (11%)
declined and 46 (60%) did not respond.
Twenty one interviews were conducted in the location of the
parents’ choice, which was usually their own home. Nineteen of the
interviewees were female and two were male. In the four cases where both parents
were present demographic questions were directed to the parent who felt they had
taken the lead role in the immunisation decision-making process. All
interviewees had a partner. The characteristics of these parents are summarised
in Table 1. Parents choosing partial immunisation most often chose tetanus and
rubella for girls. Fifteen (71%) parents made the decision not to immunise with
their first child. In 20 cases (95%) this was a joint decision made between the
interviewee and their partner. Most parents (18/21, 86%) said the health
professional from whom they received the most information about immunisation was
their own GP.
Twenty parents were able to tell us about the immunisation
advice they received during the pregnancy of their unimmunised child. Only 5 of
the 12 (42%) women who used independent midwives as their lead maternity carer
(LMC) had received information on immunisation from their midwife. Only one of
the three women who used a specialist obstetrician as their LMC had discussed
immunisation with their specialist. All four women who used GPs as their LMC had
either received immunisation information or discussed immunisation with their
GP. One woman had a hospital midwife as her LMC and received information on
immunisation from her.
Table 1. Characteristics of 21 parents who chose not to
immunise their children
Parents usually had a number of reasons for choosing not to
immunise, which are summarised as follows:
Concerns about the risk of
side-effects and complications from immunisations Eighty five per cent of
parents were concerned about the risk of side-effects from immunisations. There
was a belief expressed that adverse reactions are poorly recorded and
underestimated in New Zealand. Parents often mentioned the possible link between
immunisation and diseases such as autism, diabetes, Crohn’s disease and
asthma. Nine parents (43%) thought the risk of side-effects outweighed any
possible benefit gained by immunisation.
Concerns regarding
children’s immune system Fifty seven per cent of parents thought
that children’s immune systems should be given the opportunity to develop
naturally by delaying immunisation or not immunising at all. Many parents
thought that immunisations were given too early and that immunisation weakens
rather than enhances the immune system. They also thought that if children
contracted diseases naturally they would develop better, lifelong immunity and
this would strengthen their immune systems.
Beliefs regarding diseases
immunised against One third of parents regarded most of the diseases
immunised against as rare and not threatening to life. They saw immunisation as
an unnecessary risk to take to protect against diseases that, as one mother
said, are ‘few and far between’. Parents were more likely to
immunise their children against diseases they viewed as an immediate threat,
such as tetanus or meningitis.
Concerns about the
effectiveness of vaccines One quarter of parents thought that vaccines
were not fully effective and did not provide lifelong immunity. Parents often
mentioned cases of whooping cough in children they had known to be immunised
against this disease.
Having or knowing a child
thought to have suffered an adverse effect from an immunisation Two of
the participants were the parents of children they considered to have been
permanently disabled by reactions to a vaccine. Two other mothers’
children had experienced short-term adverse reactions such as convulsions and
extensive swelling. Based upon their experience they had chosen not to have any
of their other children immunised. Two parents mentioned that knowing a child
believed to have been damaged by a vaccination had prompted them to look at
immunisation carefully. Three parents identified the possible link between
immunisation and their own children’s health problems, including autism,
Crohn’s disease and food intolerances, as a reason for choosing not to
immunise.
Other reasons for not
immunising Other reasons mentioned included the protective effect of
breast-feeding, not wanting to see a child in pain, too many vaccines delivered
at once, belief in Rudolf Steiner philosophy, a child spending its early months
close to its mother therefore lowering risk of disease, and the use of
complementary medicine and healthy living to build up immunity.
Several parents in our sample thought that their
children’s health problems were caused by immunisation. Some of these
children had received compensation from the Accident Compensation Corporation.
We made no attempt to ascertain the likelihood that their children’s
problems could be attributed to immunisation. Many parents thought that adverse
reactions to immunisation were not accurately monitored and therefore
underestimated.
Parents were given the opportunity to comment on any aspect
of immunisation at the conclusion of the questionnaire and many parents stated
that the information supplied by their general practitioner was biased in favour
of immunisation and downplayed the risk of side-effects from immunisation. Since
both the Ministry of Health immunisation pamphlets and books and the information
available from the Immunisation Advisory Centre at the University of Auckland
(IMAC, funded by the Ministry of Health) clearly promote immunisation, these
sources are viewed as biased by these parents. Many parents expressed the desire
to have information that is provided by a neutral, third party outside the
‘medical establishment’.
DiscussionThe parents we interviewed were well
educated and had sought information about immunisation from a variety of
sources. They chose not to immunise their children due to concerns regarding
vaccine safety and efficacy as well as beliefs that diseases immunised against
are now rare and not life threatening.
A weakness of this study was its small size. The interviews
were conducted over the summer-holiday period and many GPs and families could
not be contacted, which led to a poor response rate. Non-responding GPs and
parents were not contacted again. Nevertheless, 73% of parents we were able to
contact agreed to be interviewed and these parents were uniformly eager to give
their reasons for choosing not to immunise their children.
Another weakness of this study is that all parents were
recruited from GPs’ registered patients. Parents who do not use a GP at
all for their child were not studied. We are unable to say how representative
our sample was of all parents who choose not to immunise their children.
Furthermore, we are unable to give any reliable estimate of the percentage of
parents choosing not to immunise in Christchurch as there is no comprehensive
regional record kept of this information.
Many of our findings were similar to results from other
studies of parents declining immunisation. Sixty two per cent of the parents in
our sample had a bachelor’s degree or higher tertiary qualification, which
is much higher than the New Zealand average of
11.8%.7 Studies from overseas have also
suggested that choosing not to immunise is more common in parents with higher
socioeconomic status.8 Previous New Zealand
research has indicated that better educated women were more concerned about the
perceived safety of vaccines.9
Our findings on the provision of immunisation information by
lead maternity carers confirms the findings of a New Zealand national study that
found that only 61% of mothers using midwives as LMCs had discussed immunisation
with their midwife, only 20% of women using specialists as their LMC had
discussed immunisation with their specialist, but that 81% of women who used GPs
as their LMC had discussed immunisation with their
GP.10 It would appear that the statutory
obligation to provide immunisation information to parents is being ignored by a
large proportion of both midwives and specialists. Lead maternity carers are
obliged only to provide Ministry of Health immunisation information to mothers
and are free to offer anti-immunisation information from groups such as the
Immunisation Awareness Society at the same time. Over one third of our sample
had already made a decision not to immunise before the birth of the child, which
highlights the need to give women accurate information during their
pregnancy.
Parents’ reasons for choosing not to immunise were
similar to those given by parents in studies from the UK and Australia, where
worries about side-effects, the effects of immunisation on the immune system,
and ‘natural’ immunity were the major
concerns.4,11 The next most common reason was
the belief that the illnesses immunised against are not serious risks to
health.5,12
The parents in this study were highly educated, caring
people who had all undertaken personal research and sought information from a
variety of sources before choosing not to immunise their children. The parents
we interviewed retain a high level of trust in their individual GPs, who are
their most important source of immunisation information. In contrast to the UK,
where parents have expressed distrust of GPs’ advice knowing that they are
rewarded for achieving high immunisation rates, there is no direct financial
incentive to immunise children amongst New Zealand
GPs.4,5 This may serve to increase parental
trust in their GPs’ advice regarding immunisation, and any incentives to
GPs to increase the immunisation rate amongst their patients could lower
parental trust and conceivably lead to lower immunisation rates. General
practitioners and practice nurses need to become familiar with the concerns that
motivate parents to make a conscious choice not to immunise their children and
be prepared and funded to provide accurate, detailed information on the benefits
and risks of immunisation in what will often be difficult and time-consuming
consultations.
Author information:
Matilda Hamilton, Medical Student; Paul Corwin, Senior Lecturer; Suzanne Gower,
Lecturer, Department of Public Health and General Practice, Christchurch School
of Medicine and Health Sciences, University of Otago; Sue Rogers, Immunisation
Coordinator, Pegasus Health, Christchurch
Acknowledgements: We
thank the staff at Pegasus Health and the GPs who assisted with this study; the
parents we interviewed; and Elisabeth Wells for statistical advice. Matilda
Hamilton was sponsored by the National Child Health Research Foundation in her
Christchurch School of Medicine and Health Sciences Summer
Studentship.
Correspondence: Dr
Paul Corwin, Department of Public Health and General Practice, Christchurch
School of Medicine and Health Sciences, PO Box 4345, Christchurch. Fax: (03) 364
3637; email: paul.corwin@chmeds.ac.nz
References:
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