Addressing Issues of Vaccination Literacy and Psychological Empowerment in the Measles-Mumps-Rubella (MMR) Vaccination Decision-Making

A Qualitative Study

Marta Fadda; Miriam K. Depping; Peter J. Schulz


BMC Public Health. 2015;15(836) 

In This Article


Measles is an infectious respiratory disease, which can lead to severe complications particularly in children under the age of 5 and adults over the age of 20.[1] In developing countries, measles is still one of the leading causes of death among children, although a safe, efficient and relatively inexpensive two-dose vaccination is available.[2] The most common measles-containing vaccine is the MMR vaccine, which also protects from mumps, a disease characterized by swelling of the salivary glands, and rubella, an infection that can often lead to serious complications in the fetus if acquired by an expecting mother.[1] To reach herd immunity, health authorities recommend that 95 % of the population be vaccinated.[2]

In most developed countries, parents are recommended to immunize their children against MMR, but the final decision is theirs. This policy, which calls for an informed, autonomous decision, assumes parents possess the relevant and accurate information regarding both the risks and the benefits of the vaccination compared to the disease, the skills to judge what is more appropriate for their child, and the motivation to engage autonomously in such a decision. In other words, parents are expected to be knowledgeable and empowered in order to make their choice, whether or not their final decision will meet the country's official recommendations. Indeed, even with a sound knowledge and a high level of engagement in the decision-making, different factors and cognitive processes might lead to a biased judgment, such as omission biases.[3] Although making vaccination compulsory may be seen as a strategy to boost adherence to vaccination programs, compliance with vaccination schedules in Europe is high even when vaccinations are merely recommended.[4,5]

As in most European countries, the MMR vaccination is not compulsory in Switzerland. The country is committed to the goal of eliminating measles and rubella in the European Region of the World Health Organization by 2015. However, it currently displays suboptimal MMR coverage, making measles still locally endemic.[6–8] Recent data from the Swiss Federal Office of Public Health (FOPH) show that only 86 % of 2-year-old children have received the two doses that make a full MMR course.[9]

Between 2006 and 2009, Switzerland experienced the highest measles incidence rate of Central and Western Europe, making up 29 % of all measles cases that occurred in the 32 European countries reporting to the same surveillance network (ECDC).[6] Despite a widespread prevention campaign, measles cases in Switzerland have nearly doubled in 2013 compared to the previous year.[9] In addition, Switzerland constitutes a potential source of imported measles for other countries in Europe and elsewhere, such as Germany, Denmark, England, and the United States.[6]

Research has extensively studied drivers and barriers of parental vaccination decisions. The most significant predictors of vaccination behavior include perception of the risks posed by the disease and the vaccination side effects,[10–14] beliefs and attitudes towards the disease and the vaccination[15–19] and its efficacy,[20] and safety concerns.[21–23] An extensive literature has also acknowledged the role of trust in medical professionals, health authorities, and governments,[13,24–29] and social norms.[30] In addition, religious beliefs,[31] hesitancy,[32] publicity by anti-vaccination groups[33–36] and the rise of complementary and alternative medicine (CAM) have been reported as playing a crucial role.[37–40] The pediatrician's information[41] and communicative style during vaccination recommendation (presumptive vs. participatory)[42] can also be influential on the decision. Mixed results are available for the role of demographic variables such as education,[43–46] age, race, marital status and number of children.[47–49] Furthermore, evidence suggests that immigrants are more likely to adhere to vaccination recommendations compared to the local population.[50–52] Knowledge has also been identified as an indirect driver.[10,43,53–56]

Within the extensive literature currently available on what informs parental decision regarding childhood vaccinations, several studies have specifically looked at the context of the MMR vaccination, especially after the MMR scare sparked by a Lancet article which claimed a link between MMR and autism in 1998.[49,57–59] A summary of the most common factors underlying parental MMR vaccination decision making can be found in a recent systematic review.[60]

Research has shown that a unique set of beliefs and different positive and negative attitudes surround each vaccination and its related disease(s).[29] Our study aims to explore the reasons that drive parents' MMR vaccination decision, with a careful look at vaccination literacy and psychological empowerment. To our knowledge, this is the first study addressing vaccination literacy and empowerment together in the context of parents' decision to have their child immunized or not. The MMR vaccination features a number of unique characteristics compared to other childhood vaccinations – such as being at the center of the autism controversy.[61] Moreover, administering this vaccine can be seen by parents as the closest thing to a natural infection, since it is made of live attenuated viruses of its three target diseases.[62] Studies have also shown that postponing this vaccination may have serious consequences for future outbreaks.[63]

Theoretical Background

Since parents have the final say on their children's immunization, the MMR vaccination decision is extremely sensitive to individual differences. A number of theories have addressed such behavioral differences from a variety of perspectives. Among these, the Health Empowerment Model provides a theoretical framework that considers health literacy and psychological empowerment as two equally important and independent predictors of health behavior.[64] The model has been applied to a number of contexts, including eHealth interventions[65] and studies on chronic patients' self-management.[66] Recently, its application to the context of vaccination behavior has been advocated to explain parental resistance against physicians' professional standards, suggesting the potential danger of vaccination misinformation when this is coupled with high parental empowerment.[64]

Nutbeam[67] defines health literacy as "the capacity to acquire, understand and use information in ways which promote and maintain good health". Schulz & Nakamoto[64] stress the multidimensionality of this concept, defining it as a set of four sub-dimensions: (a) functional literacy, (b) declarative knowledge, (c) procedural knowledge, and (d) judgment skills. Similar to health literacy, psychological empowerment is an intrinsic motivational construct of the individual manifested in four cognitions:[68–70] (a) meaningfulness (the extent to which what one does is perceived as being important), (b) competence (one's perceived competence to carry out an action), (c) impact (the perception of making a difference through a certain action) and (d) self-determination (the extent to which what we do is perceived as autonomous). Although the term empowerment originally focused on the individual, the collective, and the organizational levels,[71] our study shall be concerned with the individual level only. Ideally, people will possess the adequate knowledge and skills to manage their own care, but also the commitment and motivation to make autonomous and impactful decisions. For a more thorough description of the Health Empowerment Model, see Schulz and Nakamoto.[64]

In the context of parental vaccination decision, health literacy can be studied in terms of both knowledge about vaccinations and ability to find, judge and use the information encountered, in light of the high amount of inaccurate material which parents can be exposed to.[72] Knowledge can be further split into declarative and procedural. Declarative knowledge includes, for instance, knowledge about infectious diseases, the availability of vaccines, or the likelihood and severity of their side-effects. Procedural knowledge entails notions such as knowing how and when to get vaccinated against infectious diseases.[73]

Adjusted to the context of parental vaccination decision-making, the four sub-dimensions of psychological empowerment can be operationalized as following: (a) meaningfulness will refer to the degree to which an individual thinks that making a vaccination decision regarding his or her child is an important issue; (b) competence will refer to the degree to which an individual feels able to make a sound vaccination decision; (c) impact will refer to the degree to which an individual feels that making a decision over the vaccination can generate a number of outcomes; (d) self-determination will refer to the degree to which individuals think that their vaccination decision is solely determined by themselves. A study was conducted using semi-structured interviews with parents in order to explore the factors driving parental MMR vaccination decision with regards to vaccination literacy and psychological empowerment.