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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.110 n.1 Pretoria Jan. 2020 



Communication regarding routine childhood vaccination



S CooperI, II; R J BurnettIII; E Z SambalaI; B M SchmidtI; C S WiysongeI, II, IV

IPhD; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
IIPhD; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
IIIPhD; South African Vaccination and Immunisation Centre, Department of Virology, Sefako Makgatho Health Sciences University, Pretoria, South Africa
IVPhD; Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa





Vaccine hesitancy is an emerging problem in South Africa (SA), which threatens to erode the country's immunisation achievements. Communication interventions may be an effective strategy for addressing vaccine hesitancy. We highlight a Cochrane review of qualitative evidence that explored parents' views and experiences of communication regarding childhood vaccinations, and provide implications for practice that are relevant to the SA context. The findings suggest that healthcare providers (HCPs) play a central role in childhood vaccination attitudes and decision-making. Therefore, capacitating HCPs to promote vaccination with confidence is key to effective communication to address vaccine hesitancy in SA.



We discuss a Cochrane review of qualitative evidence that explored parents' views and experiences of communication regarding childhood vaccinations.[1]

One in 3 South African (SA) children does not receive basic vaccines on schedule,[2] which has led to repeated outbreaks of vaccine-preventable diseases (VPDs) in the country.[3,4] One reason for low childhood vaccination coverage may be vaccine hesitancy, which represents a continuum between vaccine acceptance and vaccine refusal. [5] Evidence suggests that vaccine hesitancy is a growing problem in SA,[6-9] which requires urgent attention if we hope to preserve the achievements of immunisation programmes. Communication interventions may be an effective strategy for addressing vaccine hesitancy.



The review of Ames et al.[1] sought to synthesise qualitative studies exploring parents' views and experiences of communication with regard to vaccination for children up to 6 years of age and the influence of vaccination communication on parents' childhood vaccination decision-making. Qualitative studies were included from any setting globally where childhood vaccination information is disseminated.


Intervention and methods

The review defined communication as 'a purposeful, structured, repeatable and adaptable strategy to inform and influence individual and community decisions in relation to personal and public health participation, disease prevention and promotion, policy making, service improvement and research'.

A comprehensive search conducted up to 30 August 2016, and subsequent article screening, produced 79 eligible studies, from which 38 were purposively sampled for inclusion in the synthesis. A 5-step thematic analysis was employed for data extraction and synthesis. Methodological limitations were assessed with an adaptation of the Critical Appraisal Skills Programme (CASP) assessment tool. Confidence in the review findings was evaluated using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach. GRADE-CERQual categorises confidence from high (it is highly likely that the review finding is a reasonable representation of the phenomenon of interest) to very low (it is not clear whether the review finding is a reasonable representation of the phenomenon of interest).



Parents found the amount of vaccination information they received to be inadequate (high confidence) and desired more information on a diverse range of topics (high confidence). Healthcare providers (HCPs) are viewed as an important source of vaccination information (high confidence), although the type of HCP consulted and level of trust in HCPs may be influenced by parents' vaccination attitudes. Parental misconceptions regarding vaccination were sometimes rooted in information that they had received from HCPs (moderate confidence). Parents generally perceived poor communication as potentially having a negative impact on vaccination decision-making (moderate confidence). Parents wanted HCPs to have open, courteous discussions with them in a non-judgemental way, answer their questions clearly, and foster a supportive environment for vaccination decision-making (high confidence).



The findings from this review suggest that HCPs play a central role in childhood vaccination attitudes and decision-making, with the potential to support or disrupt vaccination uptake. Most of the studies included in the review were from high-income countries; only 3 studies were from Africa and none was from SA. Experiences and perceptions of vaccination are context and programme specific,[10] and therefore the findings of this review need to be interpreted with some degree of caution for SA.

Implications for practice

While more research on this topic is needed in SA, the findings from this review have various preliminary implications for policy and practice in the country. A parent's trust in their child's HCP is essential for effective vaccination communication.[7] A recent Wellcome Global Monitor report found that 74% of South Africans trust doctors and nurses for medical and health advice.[10] The review also found that vaccine-accepting parents tend to trust their HCPs and were more likely to consult allopathic HCPs. In contrast, vaccine-hesitant parents were more likely to consult alternative HCPs, such as chiropractors and homeopaths, often turning to them because of a breakdown in trust in their previous allopathic HCPs. However, it was also found that some allopathic HCPs do not recommend vaccination and/or may provide misinformation, a phenomenon that also occurs in SA.[9]

For parents who do question vaccination, the review found that HCPs often did not provide clear answers. Being able to answer parents' questions builds trust, which is essential for effective communication.[7] Therefore, effective communication cannot take place when HCPs do not have up-to-date vaccinology knowledge.[7] Extended Programme of Immunisation SA (EPI-SA) managers perceive basic vaccinology knowledge to be lacking among vaccinators.[2] This perception has been confirmed by unpublished findings of the SA Vaccination and Immunisation Centre (SAVIC) at Sefako Makgatho Health Sciences University, Pretoria. SAVIC has been providing basic vaccinology training to vaccinators since 2016, with pre-intervention knowledge tests consistently indicating low levels of vaccinology knowledge. In light of the review findings, it may be that vaccination communication needs and expectations of SA parents are not being met by HCPs.

EPI-SA managers also identified vaccine hesitancy among parents as a key challenge to the success of EPI-SA,[2] a perception that is supported by the findings of the Wellcome report that 5%, 9% and 11% of South Africans, respectively, believe that vaccines are unnecessary, unsafe and ineffective.[10] Unfortunately, a combination of vaccine-hesitant parents and a lack of HCP vaccinology knowledge is a recipe for ineffective communication, further eroding vaccine confidence. The key to effective communication to address vaccine hesitancy is capacitating HCPs to promote vaccination confidently. Basic vaccinology training for SA HCPs is therefore essential.

Declaration. None.

Acknowledgements. Cochrane Corners are co-ordinated from Cochrane SA at the South African Medical Research Council (SAMRC), but the views expressed in this article are those of the authors and do not necessarily reflect the views or policies of Cochrane or the SAMRC.

Author contributions. SC conceived the manuscript and wrote the first draft, with the exception of the 'Implications for practice' section, of which RJB wrote the first draft. All authors contributed to versions of the manuscript and approved the final draft.

Funding. None.

Conflicts of interest. None.



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S Cooper

Accepted 16 September 2019

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