Concept analysis of failure to vaccinate in healthcare

Failure to vaccinate has been a problem since vaccinations were developed by Edward Jenner. Vaccines have proven to reduce the number of infectious diseases, and they are most effective in promoting public health. Some parents and caregivers, however, still refuse to vaccinate.

Getting a better understanding of the definition of the concept of failure to vaccinate as well as examining different areas of research, related terms, causes and consequences, would give healthcare professionals a new framework to focus on preventing vaccine refusal, rather than the traditional response they give to parents who are concerned about \"vaccine risks.\" Health care providers have a significant role to play in educating patients about the benefits of vaccinations.

Purpose

According to Walker and Avant (2011) concept analysis is an approach used to clarify meanings of terms and to define concepts; it is also a way to help writers and readers share a common language (McEwen & Wills, 2014). The purpose of this concept analysis is to discover the meaning of the phrase failure to vaccinate, define its attributes, examine cases scenarios, and review the antecedents and consequences of the concept. This paper will identify all uses of the concept by reviewing the common understanding of the terms (using the Merriam-Webster dictionary) and by conducting a literature review in different disciplines. By examining the concept of failure to vaccinate, this paper will use the method of Walker and Avant (2011) to conduct a concept analysis.

Review of the Literature

Dictionary: Merriam-Webster (2017) dictionary defines the word \"failure\" as: \"omission of performance; a failing to perform a duty or failure to pay rent on time. 1. A state of not being able to perform a normal function. A stop in normal function such as power failure. Giving way under stress such as structural failure. 2. Lack of success, failing in business, and bankruptcy. 3. Falling short, deficiency, deterioration, and decay. 4. One that has failed.\"

The word \"vaccinate\" is defined as: \"to administer vaccine by injection\" (Merriam-Webster, 2017).

Definitions of \"failure to vaccinate\" generally have focused on refusal to vaccinate, which is usually seen as an act of commission in which a parent or other caregiver vaccinates on an alternate schedule or chooses not to give the child the shot. The definition of failure to vaccinate can have two different meanings in some professional disciplines:

Vaccination failure: Vaccination failure can be defined variously as: 1) insufficient immune response, 2) for a vaccine that was not 100% effective, 3) when a person fails to produce antibodies to protect him or her from the disease, 4) incomplete coverage of strains, 5) immunization after exposure to pathogen, and 6) when a vaccine was not administered appropriately.

Failure to vaccinate: Failure to vaccinate could be due to administration error, such as when a wrong dosage is given, a series is incomplete because of noncompliance with recommended schedule, there is a failure to obtain the recommended booster, or a vaccine expired. There are also cases of parents refusing vaccines because of safety concerns. Some parents believe vaccines are not necessary, are harmful, or that their children will not be exposed to the disease. Parents believe this because they have not seen any outbreaks since many children have been vaccinated (Keller, 2008). According to Omer, Salmon, Orenstein et al. (2009), there were parental concerns regarding the safety of vaccines, such as associations between vaccines and autism. Omer et al. (2009) cited a study in 1998 involving 12 children suggesting that the MMR vaccine caused bowel problems and led to autism. The complaints included diarrhea and abdominal pain. Links between inflammatory bowel disease (IBD) and the MMR vaccine have also been a cause of concern for parents, and the publication of one researcher claiming a link resulted in lawsuits against the researcher (Doja, 2006). However, aside from these cases, there has been no evidence that indicates a link between the MMR vaccine and autism exists (Keller, 2008). According to Omer et al. (2009), even though the MMR concerns are not supported by scientific evidence, fear associated with this vaccine has led to many parents refusing or delaying vaccination for their children.

Vaccines have reduced the number of infectious diseases in the world, but vaccine safety has become more of a public concern in the wake of stories related to vaccination side effects. The fact that there are safety concerns regarding immunizations has led to a decrease in vaccination coverage (Andre, Booy, Bock et al., 2008). The way best to prove that vaccines are effective is to provide scientific data.

Eradication: Vaccines were first used in the United States in the 19th century. The U.S. was the first to require smallpox vaccination. The vaccine was used to prevent and control frequent smallpox outbreaks. Similarly, other states started to implement this law. Despite the challenge of being able to administer a safe vaccine, the program was effective in preventing smallpox in the 19th century. The occurrence of smallpox decreased between 1802 and 1840. There were states that passed the new vaccination law and other states were starting to enforce it (Andre et al., 2008).

In the 1960s and 1970s there was difficulty controlling another outbreak in the United States. In 1969, there were 17 states that had laws that required children to be vaccinated with the measles vaccine before starting school, and 12 states had a requirement for vaccination against six diseases. During measles outbreaks, there were states that did not allow students to attend school who did not comply with immunization requirements. By the 1980s, school immunization was required in all 50 states (Omer et al., 2009).

Elimination: Diseases can be eliminated by getting rid of the causative microorganism. One way of preventing a measles outbreak from occurring is to get the MMR vaccine, which also helps eradicate both rubella and mumps. The measles vaccination has been successful in controlling a disease that contributed to significant morbidity and mortality. In the United States, the the number of cases of measles dropped as a result of vaccination. Between January 1, 2008, and April 25, 2008, there were five measles outbreaks. All of them except one person with measles was either not vaccinated or did not indicate ever getting the vaccine. The 21 cases were of children and adolescents with a known reason for not being vaccinated -- i.e., they had a nonmedical exemption (Omer et al., 2009).

Prevention of infection: Many vaccines are to prevent disease and not protect against infection. There are some vaccines that do protect against infection. Hepatitis A vaccine has helped protect against infection. HPV helps protect against cervical cancer (Andre et al., 2008).

Protection of the unvaccinated: Outbreaks often start with persons who refused vaccination; a disease then spreads to unvaccinated populations and also spreads to other population. In the past several several years, immunization rates have declined in the Unites States. Decreased immunization rates threaten herd immunity and can result in children being unable to attend school. Parents were cited as refusing vaccines because of the concerns about the safety of the vaccine. According to Sheriff, Hendrix, Downs et al. (2012), one parent was dead-set against immunization and would not change her mind. Other parents were \"vaccine hesitant\" but willing to learn about the immunizations. Overall, the population sampled indicated that \"much of the public discussion of vaccine safety and immunization policy has focused on personal issues, such as the benefit or risk to an individual child and a parent\'s right to decide on whether their child gets immunized\" (Sheriff et al., 2012).

Defining Attributes

Defining attributes, similar to signs and symptoms, are critical characteristics that help to differentiate one concept from another related concept and clarify its meaning (Walker & Avant, 2005). For the \"failure to vaccinate\" concept, it has been shown that parents refused to vaccinate due to a wide variety of reasons. Defining attributes of failure to vaccinate include: belief, attitudes, and behaviors and feelings.

Parents have the belief that vaccines are bad and think the MMR vaccine causes autism. One parent said her son developed autistic and digestive symptoms shortly after getting the first MMR dose. The first MMR vaccine is usually given between the ages of 12 and 15 months, which would be before you would notice signs of autism. The timing of the vaccine might make parents think that there is a relationship between the two. Parents who have a child with autism may decide not to vaccinate the younger siblings with the MMR vaccine. The Institute of Medicine did not find a relationship between the MMR vaccine and autism. A study was done that concluded that the MMR vaccine was not associated with autism, regardless of whether older siblings had autism. Understanding vaccines and the research related to autism will help providers give parents accurate information (Barrows, Coddington, Richards & Aaltonen, 2015).

Some parents also believe that children receive too many vaccines at a time and want to split up the shots. There are parents who believe their child has vulnerable immune system and should not receive all the vaccines at once. There are parents who believe that giving the combined MMR vaccine might overwhelm the child\'s body and lead to sickness. However, there are also parents who think their children are healthy and vaccines would not benefit them: \"These parents believe that if their healthy child does contract a disease naturally, it would be beneficial and lead to the development of long-lasting immunity\" (Barrows et al., 2015).

The most common attitude that parents have toward vaccines is that they feel they are not provided with enough information about vaccines (Gust, Kennedy, Shui et al., 2005). Parents who are less educated do not know much about vaccines and find it difficult to ask questions to the providers. Parents who are not well educated about vaccines have shown concerns about vaccine safety and expressed distrust toward health care providers. According to Gust et al. (2005), providing information to parents is a factor that has been shown to influence a sense of trust in patients, and not providing enough information to a patient is one factor contributing to non-immunization among children (Gust et al., 2005).

Parents\' behaviors and feelings about vaccinations and how they make the decision or whether or not to vaccinate their children are complex. Some parents might refuse to vaccinate because they feel it will harm their child. Or they might switch health care providers who are willing to vaccinate on an alternative schedule (Eritsyan, Antonova & Tsvetkova, 2017). One qualitative study on the influenza vaccine was performed in which the participants who were mothers felt that the decision to immunize their children was personal: \"The idea of immunizing children to protect others, particularly older people, did not resonate with these participants\" (Sheriff et al., 2012).

Definition

People who do not vaccinate their children are misinformed and tend to base their decisions on suspect sources of information; and, once having made up their mind, they are unwilling to learn about the risks and benefits of vaccination. Questions that remain to be answered are: Why do parents refuse to listen to more or alternate evidence? Is it a series of events or a personal experience that compels them to be so rigid?

Antecedents

Antecedents are defined as an event that occurs prior to the occurrence of the concept (Walker & Avant, 2005). There is comprehensive literature and antecedents for failure to vaccinate. It could be from personal experiences or reading bad literature.

Parents may chose not vaccinate due to a personal experience they had with the doctor. When the parents see the pediatrician they have many questions about vaccines and want answers. Parents who are usually concerned about the safety of vaccines want to be provided with as much information as possible, especially if a sibling had an adverse reaction. Here is an example: \"Our child\'s pediatrician provided very little information on vaccines. She had a very biased and vague handout which seemed to be fueled by a public health perspective (pro-vaccine) . . . I still feel ill equipped to make this decision\" (Doha & Roberts, 2006). According to Omer et al. (2009), health care providers have a positive effect on parents\' decision on vaccinate their children. There was a study done that showed that parents were twice more likely to consider vaccines if decisions were influenced by healthcare provider. There were other parents who wanted information specific to their concerns to be discussed by the provider. This showed that healthcare providers play a role in explaining the risks and benefits of vaccines as well as addressing their concerns (Omer et al., 2009).

Also, parents may refuse to vaccinate by reading misleading information about vaccines. Some parents believe vaccines contain mercury, aluminum, and formaldehyde. Many parents worry about mercury and request thimerosal free vaccines. This is an example of a mother who thinks the mercury in the vaccine caused her child defects: \"My son was born a healthy child. As time went on and the more he was vaccinated, the more he started to change. Not knowing that mercury was in vaccines until he was four years old, I had no idea what was truly wrong with him. I was outraged that I was not told that the most powerful neurotoxin was going to be injected in my new born child. It was devastated and it changed our lives forever. I am dedicated to advocating for safer and mercury free vaccines and helping to educate parents by raising awareness of the mercury and the other dangerous ingredients in our vaccines\" (Doha & Roberts, 2006). Thimerosal has been removed from all vaccines since 2001. Only multi-dose flu vaccines contain thimerosal. Vaccines have aluminum salts but only so as to enhance the body\'s immune response to greater antibody protection. Aluminum can cause redness at the injection site. There is little formaldehyde in the vaccine to preserve it.

Consequences

Consequences are defined as events that occur as a result of the concept (Walker & Avant, 2005). Failure to vaccinate has significant consequences because it can cause harm to others who have not been vaccinated yet. A child\'s immune system is more vulnerable when not vaccinated. Unvaccinated children have a greater risk of transmitting the disease to others, especially those who have a suppressed immune system. Another consequence is requiring a child to stay out of school and having someone to miss work to stay home with the child during the outbreaks (Tan & Rothstain, 2013).

Children who are not vaccinated may get a fever more often than others. Also, they have a greater chance of getting these illnesses which include: certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, meningitis, seizures, deafness, and other severe and permanent effects from these vaccine-preventable diseases are possible as well (Tan & Rothstein, 2013). When these unvaccinated children come to the office when they are sick, they will require more testing. Most hospitals recommend IV blood tests, urine test, a chest x-ray, and sometimes a spinal tab. Based on the results, children are treated with antibiotics or might require to be continued to be monitored for twenty four hours in the hospital. Children who are not vaccinated are at greater risk for bacteria infections. For children who are unvaccinated about 5-8% of them develop meningitis (Tan & Rothstein, 2013).

Getting vaccines can protect children and adults from certain infections. Measles can cause pneumonia, healthy infants die of pertussis every year, mumps can cause infertility in males, hepatitis can cause liver damage, and a pregnant woman who gets rubella is at risk of delivering a baby with birth defects (Diekema, 2009).

Empirical Referents

Empirical referents are classes and categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself. Empirical referents, once identified, are extremely useful in instrument development because they are clearly linked to the theoretical base of the concept, thus contributing to both the content and construct validity of any new instrument (Walker & Avant, 2005). There are several commonly used instruments to assess failure to vaccinate such as The Poison Needle, Suppress Facts About Vaccinations, Internet books, Making the Right Decision for Your Child by Dr. Robert Sears, and How Robert Kennedy Distorted Vaccine Science by Seth Mnnokn.

Summary and Conclusions

The purpose of getting toward the truth about why parents refuse to vaccinate is to seek an answer from the perspective from various parents. Although I may not be able to find the real meaning of failure to vaccinate I came close to understanding why some parents refuse. In order to have a better understanding, more research and tests were needed to refine the failure to vaccinate definition and attributes. In nursing, failure to vaccinate could be used to assess why patients refuse to vaccinate their children. Failure to vaccinate influences belief, attitudes, and behaviors and feelings in parents. Nurses have to understand parents\' behavior towards vaccines. Through understanding, they can focus on ways to change the parent\'s attitude towards vaccines by changing their behavior.