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


The aim of this study was to qualitatively explore parents' vaccination literacy and psychological empowerment in the MMR vaccination decision-making in the Canton of Ticino, Switzerland. Since the administration of the first dose of the MMR vaccination is recommended in Switzerland when the child turns 1-year-old, we conducted semi-structured interviews with parents of children aged less than 12 months residing in the Canton of Ticino. This helped prevent making erroneous observations that are likely to occur if one asks decision criteria after a decision was made, for cognitive dissonance theory[81] suggests parents might forget the reasons that guided their decision or justify their behavior on the basis of their later experience.

Regarding vaccination literacy, our results showed that several parents spontaneously reported a belief that the non-compulsoriness of the MMR vaccination in Switzerland is the result of the low likelihood to catch measles that the country enjoys. Furthermore, some parents believed that Switzerland has both compulsory and recommended vaccinations, and translated the non-compulsoriness of the MMR vaccination as further evidence that it was not a necessary preventive measure. This belief can be explained by the fact that some European countries still have both mandatory and compulsory vaccinations. Thus, vaccination literacy has to entail, among other skills such as factual knowledge on the risks and benefits of the vaccination, a correct understanding of the scope of current vaccination policies, since these parents questioned the need for vaccinating.[82] Parents' misinterpretations of the aims of the recommended vaccination schedule might be linked to parents' lower risk perception of the disease, which has often been reported among the main predictors of vaccination behavior,[10,12–14,60,83] to a refusal of the official schedule or the adoption of unconventional and unsafe preventive measures. Paradoxically, while current vaccination policies are meant to empower parents to facilitate an autonomous decision (e.g. by means of the free choice), parental misinterpretation of the freedom to decide over the vaccination sets the basis for a dangerous self-management of the child's health. It follows that, if current empowerment strategies are not combined with the promotion of vaccination literacy (i.e. the understanding of current policies and the acquisition of accurate information on the benefits of the MMR vaccination and the risks of contracting diseases such as measles, mumps or rubella), parents are likely to underestimate the benefits and opt for alternatives that clash with official recommendations.

Regarding psychological empowerment, themes related to autonomy (or self-determination) and perceived competence emerged. We found that, in line with previous findings,[84] parents' perception of lacking expertise about the MMR vaccination and its target diseases, their inabilities to understand medical information, and their perceived incompetence in assessing the reliability of the information encountered may constitute a barrier to their active participation in the decision-making and, thus, to an autonomous decision. Our findings indicate that a perceived lack of knowledge on the MMR immunization and the target disease(s) led some parents to completely devolve their decision on the pediatrician, giving up their self-determination. For other parents, social influences might play a central role when they do not believe to be competent in making the decision themselves, with some parents opting for a culturally-embedded decision or for what has been previously done within the broader family.[85] However, our findings add that parents with a low perceived competence might nevertheless opt for an autonomous decision. In this case, we found that some parents had a preference for a gut-driven choice and that this, in turn, could be influenced by feelings of fear and anticipated regret derived from attendance of anti-vaccination meetings. Perceived competence and self-determination appear then to be unrelated. In some cases parental decision will lack both the self-determination which characterizes an autonomous choice and the perception of being competent to make an informed decision, two characteristics currently advocated by vaccination policies. In other cases, the perception of being unable to make a decision does not constitute an obstacle to parents' self-determination, who might follow their own instinct and make an autonomous decision, running the risk of being at the mercy of anti-vaccination supporters or old-fashioned and unsafe beliefs. This might have serious implications for the formation of beliefs on the safety of the MMR vaccination, since most anti-vaccination narratives include, for instance, stories of children who allegedly became autistic after receiving the MMR jab.[86,87]

Regarding importance (or meaningfulness) and impact, two sub-dimensions of psychological empowerment, it appears in the results that the MMR vaccination decision is listed by all parents among the most important decisions made for their child, including parents who have a negative attitude towards the MMR vaccination, who mainly worry about the vaccine's side effects on the child. This is in line with previous studies.[53,88] However, while importance comes as an obvious component of the decision, independently of the attitude towards the vaccination, this theme is enriched by the finding that parents' concerns address three main levels which the MMR vaccination decision can have an impact on, namely the child's life, the family life-style, and the community/society. Commitment to preserve one's child and other children from the disease was found to be a predictor of parental vaccination decision,[15] as well as parental concerns about a vaccination decision affecting family life-style,[89] and these issues are mainly cited by pro-vaccination parents. For some parents, importance was conceived in terms of contingency and stress, in the sense that the MMR vaccination decision was deemed less important than other choices since it did not require long and constant organizational efforts.

In their quest for vaccination literacy and psychological empowerment, most parents seem to find a potential and desired ally in the pediatrician. Parents' expressed a need for shared vaccination decision-making with the child's healthcare provider, and this is in line with previous studies that reported discussion with a doctor was associated with receipt of the vaccination.[90,91] Ideally, shared decision making (SDM) in the context of childhood vaccination decision would be characterized by the pediatrician explaining the risks and benefits of the vaccination according to the individuals' competences, listening to parents' preferences, and discussing the decision with both parents so that the decision is informed and made in accordance with parental values and needs.[45] Parents mainly advocated more discussion with the pediatrician prior to making the final decision as a way to be more involved and, thus, build their path towards a self-determined choice. Also, they asked to receive quality and tailored information on the risks and benefits of the vaccination according to their skills, which will lead to a perceived competent choice. Finally, they want the pediatrician to provide factual and procedural information, and tools to find, access, and understand this information, which is in line with what vaccination literacy would entail. Many parents felt that they could make an empowered decision, but that this did not mean being entirely independent and without the pediatrician's advice. Rather, they felt the need for an expert guide to better understand the risks and benefits of the vaccination, in order to make a choice that could ultimately be driven by themselves. This partly contradicts Opel's and colleagues'[42] finding that pediatrician's communicative style (presumptive vs. participatory) was related to vaccination receipt, in the sense that a presumptive approach was found to be correlated with higher compliance. This difference can be explained by cultural differences, as Opel's study was conducted in the US. A similar study should be conducted in Switzerland to assess whether parental needs for shared decision-making are in accordance with preference for a presumptive or participatory style by the pediatrician.

Limitations of the currents study include that parents who accepted to participate in the study were most receptive to the topic of childhood vaccinations and more prone to discuss their experience and position. Due to the qualitative nature of the present study and its limited sample size, it should also be stressed that our findings cannot be generalized to the whole population. Moreover, social desirability bias should be taken into account, since participants might be more prone to present themselves as compliant with official recommendation, especially when they mentioned that adherence to the vaccination schedule for their older children was meant to secure immunity within their community. Furthermore, since the Italian-speaking part of Switzerland has a higher MMR vaccination coverage compared to the rest of the country,[6] exploring the concepts of vaccination literacy and empowerment in a low coverage area might have yielded different insights. However, our diverse recruiting system helped us minimize these limitations ensuring a diversified sample in terms of country of origin and life-styles. Parents with an immigration background represented a large percentage of our sample. However, this is in line with current statistics on the migrant population in Switzerland. Moreover, as qualitative research is context-bound, parental reports are to be interpreted according to the Swiss context and healthcare system that immigrants necessarily navigate and integrate with their past beliefs. Qualitative research may represent an effective tool to understand health practices at the local level.

Our study stresses the importance of vaccination literacy and empowerment in the MMR vaccination decision making and, most importantly, of pediatricians as both literacy and empowerment providers during such a decision. First, if parents are given permission to participate in the decision, then the matter to be decided (vaccinating or not) appears to them to be unimportant - this seems to be an important and so far undiscovered and unwanted side effect of psychological empowerment. Second, the participants seem to be quite aware of their low competence in deciding about vaccination. If parents do not feel that they have the knowledge and the skills (in other words, the literacy) required to make a decision on their own, they will delegate other stake-holders to determine their choice, giving up their self-determination and, worse, running the risk of devolving the decision to anti-vaccination actors. Third, parents also seem to be quite aware of the tension between low literacy and high empowerment, mainly because they wish for more participation of pediatricians. This points to the interesting part that people share some understanding of the central premise of the health empowerment model: namely that high empowerment not accompanied by a high literacy is a dangerous thing.