Professional Documents
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Rumetta-VH N Malaysia
Rumetta-VH N Malaysia
Rumetta-VH N Malaysia
a r t i c l e i n f o a b s t r a c t
Article history: Background: Vaccine-related diseases are increasing in developing countries. This study aimed to explore
Received 27 November 2018 parents’ reasons for refusal of childhood vaccinations in Malaysia and their recommendations on address-
Received in revised form 14 June 2019 ing their concerns.
Accepted 28 July 2019
Methods: A qualitative study design involving individual both face-to-face and online in-depth interview
was used. The topic guide was developed from the Health Belief Model theoretical framework. Seven
Keywords:
face-to-face and seven online interviews were conducted with parents in the Klang Valley (an urban
Primary health care
area) who had refused childhood vaccination. All interviews were audio-recorded, transcribed verbatim
Vaccines
Treatment refusal
and checked. Thematic approach was used to analyze the data. Data was collected until data saturation
was reached.
Results: Findings were summarized into two main categories: Personal Health Beliefs and Vaccine Related
Concerns. Six personal health beliefs were identified: lack of confidence in modern medicine and health
care personnel, pharmaceutical conspiracy to sell medicines, preference to a natural approach to health,
personal instincts, religious beliefs and having a partner with similar beliefs. Four main vaccine-related
concerns were identified: negative effects and content concerns, doubts of necessity and lack of infor-
mation and knowledge regarding vaccines. Parents recommended that more empathy from healthcare
professionals and evidence on safety and content purity would help them reconsider vaccination.
Conclusion: Parents had multiple reasons for refusing childhood vaccinations but felt that communication
and empathy from healthcare professionals was lacking. Besides individual consultations with parents,
addressing these concerns at multiple levels in the health care system and society may help to increase
the uptake of childhood vaccinations in the future.
© 2019 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jiph.2019.07.027
1876-0341/© 2019 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
200 J. Rumetta et al. / Journal of Infection and Public Health 13 (2020) 199–203
movement was given widespread media attention [5,9]. This lead Table 1
Participant demographic information.
to parents who refuse vaccinations avoiding detection due to
fear of being ‘hunted down’ which could make them reluctant to Demographic n
discussanti-vaccination views in consultations. Age (mean, range), years 37.4 (28–49)
Gender
Study aim Female 13
Male 1
Ethnicity
This study aims to explore Malaysian parent’s reasons for vac- Malay 7
cine refusal and to report their views on recommendations on Chinese 4
discussing their vaccine-related concerns. Findings from this study Indian 3
Education level
will shed light on the growing trend of anti-vaccination in devel-
Diploma 1
oping countries and help healthcare professionals (HCPs) discuss Degree 12
vaccine refusal with parents from these regions. PhD 1
Number of children (mean, range) 2.6 (2–6)
Methodology
Table 2
A qualitative approach was taken in this study to enable Summary of findings.
exploration of the factors that influence parents’ decisions not
Reasons for vaccine refusal
to immunize their children. In-depth interviews (IDIs) were con- 1 Personal health beliefs
ducted in two ways: face-to-face interviews and online messaging • Lack of confidence
service interviews (Facebook Messenger). The online interviews • Pharmaceutical conspiracy
• Natural approach to health
were conducted for participants who requested convenience and
• Religious beliefs
privacy. Furthermore, the internet has been reported as the primary • Instincts
source of vaccine information in Malaysia [8]. Each participant • Partners with similar beliefs
received RM50 (USD 12.50) as a reimbursement for their time 2 Vaccine-related reasons
and/or travel. Ethics approval was obtained from The University • Negative effects of vaccines
• Vaccine contents
of Malaya Medical Ethics Committee (UMMC MEC ID.NO: 20156-
- Religious restrictions
1444). - Toxic and impure contents
• Doubts on necessity of vaccines
- Ineffectiveness of vaccines
Participants and setting
- Vaccine preventable diseases not a threat
• Lack of information, knowledge and understanding of vaccines
Participants were recruited via purposive sampling and snow- Sources of information
balling. They were recruited by physicians at the Primary Care 1. Internet
Clinic in University of Malaya, through friends and relatives as well 1. Online groups
1. Friends and relatives
as online communities. The inclusion criteria were parents who
1. Books
refused any type of childhood vaccination and resided in Klang Val- 1. Doctors
ley. Interviews were conducted over a period of 16 weeks between 1. Forum
1st September to 31st December 2015. A topic guide was devel- Recommendations
1. Vaccine-related
oped based on the constructs of the Health Belief Model and used to
• More testing and assurances on safety
guide the interviews. Face-to-face IDIs lasted half-an-hour to one • Provide AEFI-related compensation
hour whereas online interviews lasted up to eight hours as they • Avoid combination vaccines
were interrupted by pauses and breaks. Recruitment was stopped 1. HCP-related
when data saturation was reached which determined the sample • Provide more information before vaccination
• Communicate empathetically
size.
Analysis The findings of this study could be divided into reasons for
vaccine refusal, sources of information, and recommendations for
All interviews were transcribed verbatim and checked for accu- uptake. A summary of the findings is given in Table 2.
racy. The data from the interviews were analyzed using NVivo10. The reasons parents refuse vaccination for their children found
Three researchers used a thematic analysis approach for data anal- in this study can be divided into two main categories: personal
ysis, based on Strauss and Corbin’s method of open, axial and health beliefs, and vaccine-related reasons.
selective coding to develop an initial coding framework [10]. Sub-
sequent interviews were coded by the main researcher. Regular Personal health beliefs
meetings were held to evaluate the content and structure of the
emerging coding framework and any discrepancies were resolved Parents expressed a range of health beliefs which played an
through discussion. important role in motivating them to refuse vaccination. These
beliefs involved their belief of health and illness, attitudes to health
Results services and views of a disease. Six categories of personal health
beliefs identified among our participants which influenced their
A total of 14 participants were interviewed at which point data decisions about vaccination:
saturation was reached (Table 1). From the seven participants of
the face-to-face interviews, there were five Malay mothers, one Lack of confidence in modern medicine and distrust of health care
Chinese mother and one Indian father. The online interview partici- personnel
pants were all mothers: two Malays, two Indians and three Chinese. Participants expressed their lack of confidence in mod-
All participants had received tertiary education. ern medicine and health care personnel, particularly doctors.
J. Rumetta et al. / Journal of Infection and Public Health 13 (2020) 199–203 201
Participants believed modern medicines did not cure or treat dis- Vaccine related reasons
eases; as one participant said: Most participants refused vaccines for their children due to fac-
tors related to the vaccine itself. In this study we found four factors
“Western medication does not heal permanently. They don’t
related to vaccines that influenced participants’ decision to refuse
heal the root cause.” (Mrs. SM/F/38/online).
vaccination:
Participants who believed this had past experience using mod-
ern medication which did not cure their illnesses: “So we went to Negative health effects of vaccines
the doctors many times and the doctor’s medicine would not help at Almost all participants were concerned about the negative
all. But we would keep on eating the medicines. . ...the antibiotics and health effects of vaccines. Many strongly believed that vaccines
all” (Mrs. LW/F/40). came with multiple short-term and long-term side effects that
As participants viewed vaccines as modern medications, they were potentially life-threatening. Some of the negative effects men-
believed that vaccines were also ineffective in preventing diseases. tioned were the development of asthma, eczema, autism and even
brain injury.
The term AEFI (Adverse Events Following Immunization) was
Pharmaceutical conspiracy
used by certain participants. This was defined as any untoward
Some participants believed that vaccines are manufactured by
medical occurrence which follows immunization and which does
pharmaceutical companies for their own profitable gains and not
not necessarily have a causal relationship with the usage of the vac-
for the prevention of diseases. They believed these companies were
cine. The adverse event may be any unfavorable or unintended sign,
in collusion with doctors who marketed vaccines for monetary gain.
abnormal laboratory finding, symptom or disease. The following
“Well the pharmaceutical companies wanting to make money quotes illustrate how the participants’ own experiences and their
All these so called convenience of creating the so called 6 in 1 children’s experiences had influenced the participant’s decision on
jab is crazy” (Mrs. MY/F/online) not to vaccinate.
“Yes yes. . .personally. . ..when I was young. . .I developed aller-
Natural approach to health and immunity gic reaction to tetanus vaccine” (Mr. MK/M/32)
Participants practiced an approach to health that was described “To me, my main concern is aefi. I saw what happen to my step
as “natural”; this meant avoiding ‘unnatural’ man-made medica- son (asthma and obesity) so idont want to risk my children”
tions such as vaccinations. Substances that are viewed as unnatural (Mrs. AS/ F/38/online)
were believed to be unnecessary; the argument was that the human
body was not made to be dependent on them to function normally. Vaccine contents
Participants were concerned regarding the contents of the vac-
“I believe that when a child is born that we should be as natural
cines. Concerns were from religious as well as health perspectives.
as possible. We don’t want to put things in our body that are not
Muslim participants expressed their concerns on the ‘non-halal’
natural.” (Mrs. LW /F/40)
(Islamic religious impurity) contents of vaccines which prevented
These participants also believed that immunity that was them from vaccinating their children despite approval on the usage
obtained through contracting the disease was better than vaccine- of the vaccines by religious authorities [11].
induced immunity as it would last longer and was a stronger type
“. . .tak halal kan, vaccine nimemangtak halal, dah sahharitu.
of immunity.
KKM pun dah keluar. Vaccine yang halal, 2017 nantibaruada.”
“I think it’s better to obtain the immunity naturally by falling (Vaccines are not “halal”, it’s confirmed. Ministry of Health has
sick” (Mrs. JC/40/F/online) confirmed it. Halal vaccines will only be available in 2017.) (Mrs.
NS/F 28)
Religious beliefs Another concern was toxic contents like mercury and aluminum
Participants argued from design that if God created humans to that were potentially harmful. One participant whose daughter was
withstand diseases by giving them an immune system, then vac- diagnosed with cerebral palsy at two monthswas convinced the
cines were unnecessary: heavy metals in the vaccine were the cause of it: “High level of heavy
metal in a 2 year old body (After vaccination). And the sudden stiffness
“Another one is my belief if God created us you know. Human
of her body” (Mrs. MY/F/40/online).
beings. . .when there is no disease yet. . .why do we need vac-
Others mentioned that impurities such as animal and aborted
cine?” (Mrs. LW/F/40).
fetus cells were used in the production of vaccines. They felt this
was dirty and unacceptable for their children:
Instincts
“the method they use I don’t know some I read the method they
Two participants mentioned that their decisions were made
use from like a monkey or animals they use from dirty the dirty
based on their instincts. Instincts were described as a gut feeling
things itself” (Mrs. MZ/F/36)
that they should not vaccinate their children. “I make decision some-
times also. . .I make decision sometimes also is just my instinct.” (Mrs.
Doubts on necessity of vaccines
LW/F/40)
Participants believed vaccines were unnecessary as they were
ineffective, that the diseases they prevented were curable and that
Partners with similar beliefs VPDs were not a threat anymore.
Most participants had made the decision not to vaccinate jointly
“Her (a friend) son was always sick. And gotten almost every-
with their partners. Having partners who also refused vaccination
thing he was vaxxed for Measles, chicken pox, whooping cough
reinforced their decision to refuse vaccination for their children:
etc” (Mrs. LYY/F/40/online)
“Yes. . .yes. . . we made the decision together after what hap- “Diseases are mostly eradicated because of improve sanitations,
pened to A . We are supportive of each other. I’m grateful for better sewerage system. Cleaner living condition, knowledge of
that” (Mrs. MY/F/40/online) nutrition.” (Mrs. LYY/F/40/online)
202 J. Rumetta et al. / Journal of Infection and Public Health 13 (2020) 199–203
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