AN INTEGRATIVE REVIEW

An Integrative Review

Nursing Research NUR 4122

Ashley Bingham

March 29, 2017

I pledge - Honor Code

AN INTEGRATIVE REVIEW 2

Abstract

The aim of the integrative review is to explore and review the literature of why parents choose not

to vaccinate their children. Childhood vaccinations are an important way to protect against deadly

communicable diseases. Vaccinations create herd immunity and protect those at higher risk, such

as the elderly and infants. Despite the worldwide use of vaccinations, parents still choose not to

vaccinate their children. Deciding not to vaccinate a child, not only leaves the individual at high

risk of contracting a fatal disease, but also leaves the community and population at risk. The

electronic database, PubMed, was used to locate research articles. 210 articles were found and

five were used in discussion of this integrative review. All five articles contain data as to why

parents choose not to vaccinate. It should be noted that there are limitations to the review due to

the researchers limited experience and knowledge on the subject as well as time limitations based

on a submission deadline. More research should be conducted to continue to best understand why

parents choose not to vaccinate and what can be done to support this vulnerable population of

children.
AN INTEGRATIVE REVIEW 3

An Integrative Review

Vaccinations have been around for hundreds of years and have provided immunity to

entire populations against potentially deadly communicable diseases. The trend of choosing not

to vaccinate has become increasingly popular over the past decades. Researchers seek to find out

why parents hesitate or refuse vaccines to have a better understanding of this cultural shift. This

shift impacts global and community herd immunity as well as increased occurrence of incidences

in disease breakouts. The goal of this integrative review is to compile research related to the

researchers PICO question, how does parent hesitancy or beliefs affect vaccination

administration to children? There are currently hundreds of research articles on this topic, but

there still needs to be more research conducted to provide substantial information to the relevant

fields to encourage more support for permitting vaccinations for children. The researcher is a

supporter of childhood vaccinations. The research was curious as to what causes this hesitancy

that leads to little or no protection for children who do not have a voice in this decision.

Design and Search Methods

This integrative review was started with searching one electronic database, PubMed.

Five articles were chosen in support of the researchers PICO question. These five articles will

remain the focus of this integrative review. The following keywords were used in the database

search: vaccination, immunization, resistance, hesitancy, childhood diseases, qualitative

methods, decision making, beliefs, parents attitudes, and childhood routine vaccinations.

In order to maintain contemporary data, articles were chosen based on published date between

2012-2017. Four of the articles are qualitative and one is quantitative. Inclusion criteria

included: being peer reviewed, having free access to the full article, and being published in
AN INTEGRATIVE REVIEW 4

English. Exclusion criteria was set based by reading the articles abstract, most of which did not

fit the PICO question.

Findings/Results

The findings and results of the articles identify the many reasons why parents choose not

to vaccinate their children. A lot of the same influences are identified among the different

articles. A synopsis of the five articles is organized and available in the Appendix. Each article

has defined children differently, less than 16 years old, (Gross, Hartmann, Zemp & Merten,

2015), less than 4 years old (Harmsen, Mollema, Ruiter, Paulussen, Melker & Kok, 2013), less

than 12 years old (Kaaijk, Kleijne, Knol, Harmsen, Ophorst & Rots, 2014) and less than 24

months old (Delkhosh, Negarandeh, Ghasemi & Rostami, 2014). One article does not define

child by age, but rather by children who visit an Anthroposophical Child Welfare Center

(Harmsen, Ruiter, Paulussen, Mollema, Kok & Melker, 2012). All four qualitative studies data

collection was analyzed using thematic analysis with the use of a coding catalog tool. The

following categories are representations of the themes discussed in the articles: parental

beliefs/lifestyle, information need/mistrust, number of vaccinations in a single visit, and

alternative vaccination delivery methods.

Parental Beliefs/Lifestyle

Three of the qualitative studies all gathered data on parental beliefs and lifestyles that

influenced vaccine hesitancy or refusal. Gross et al. (2015) conducted 32 interviews, where

many parents believed in letting their child acquire immunity through natural bodily defenses. A

major influence of choosing not to vaccinate was in support of the evolution of the human body

and its ability to fight of disease. Along with natural immunity came the support for breast-
AN INTEGRATIVE REVIEW 5

feeding and eating natural foods. Some parents establish that vaccines are an artificial intrusion

to the body that can effect the natural immune system in their childrens period of development.

Some parents choose not to vaccinate because of the Anthroposophical lifestyle.

Harmsen et al. (2012) explores why parents choose to postpone or refuse vaccinations based on

these beliefs. The authors conducted 16 interviews using three focus groups. One parent said

during an interview that, According to anthroposophy, some childhood diseases contribute to

your personal development, diphtheria, tetanus and polio are not part of that development and so

we accepted this vaccine (Harmsen et al., 2012, p.3). These parents felt their lifestyle supported

a healthy immune system, such as using a babysitter for their children instead of sending them to

a childcare center. Some mothers commented on breastfeeding and how this provides their

children with protection.

In the data founded by Harmsen et al. (2013) the main determinant of choosing not to

vaccinate was lifestyle. The researchers used eight online focus groups and had a sample size of

60. Parents attributed eating healthy, avoiding childcare and travelling, and breastfeeding for

sometimes up to two years as practices to build immunity for their children. Many of these

parents believed that since these communicable diseases have been reduced dramatically in

occurrence, there is less need to vaccinate, and that their children are at considerably low risk.

Information Need/Mistrust

The lack of information was looked at from many different aspects, such as how the

information was portrayed and appropriate use of language to the lay person. One aspect was the

lack of specific information about the vaccine, to include chemical components and efficacy. A

second component was mentioned about the parents ability to interpret the information that was
AN INTEGRATIVE REVIEW 6

provided and how their understanding supported their vaccination decisions. Three of the

qualitative studies gathered data about lack of knowledge.

Harmsen et at. (2012) found that information need was a topic that all participants (n =

16) discussed in their interviews. Parents expressed a need to have more scientific information

such as risks, including fatal cases, and side effects and their occurrences. The need for

transparency from the Public Health Institute (PHI) would likely decrease their mistrust with the

information they were able to find on the internet. They should also be given access to a list of

references to deduce if the information was also reliable. Parents further suggested making more

information available to child vaccine providers (CVP) who will be in direct contact with the

parent and their children. With CVPs having this information, they will be prepared to provide

additional support for these families and their vaccination concerns.

The need for information was also a theme in the research conducted by Harmsen et al.

(2013). Many parents mentioned in their interviews that they do not receive enough information.

They had only received information about the injection itself, such as pain at the site and

possibility for fever. They did not receive any information pamphlets about the vaccination, side

effects, or negative outcomes. This causes some mistrust with the National Immunization

Program (NIP). Parents who wanted more information had to seek it on their own. This was

overwhelming as they did not know how to determine what sources are reliable and trustworthy.

Providing information will also help parents who have a false misconception about

vaccines, which was noted in the research by Delkhosh et al. (2014). Researchers conducted

interviews with 26 mothers in Tehran, Iran. One mother thought her child would become

paralyzed after receiving the polio vaccine. Healthcare workers can play a tremendous role in

making sure parents are well informed about the benefits and risks of vaccinating their child.
AN INTEGRATIVE REVIEW 7

Educating on the common, yet mild, side effects of vaccines will help to decrease a mothers fear

of the vaccines and may encourage her to not refuse immunizing her child.

Number of Vaccinations is a Single Visit

In the quantitative study by Kaaijk et al (2014), some parents believe that having 3 or

more vaccines during a single visit caused too much pain and discomfort for their child, the

majority of parents (69%) indicated that 3 vaccine injections per visit is too much (Kaaijk et al.,

2014, p. 2486). This alone encourages the parents to refuse some vaccines. Interestingly

enough, even though these parents were against the number of vaccines in a given time, they

were in favor of extending the vaccine program, if new vaccines to protect against other

communicable disease were available. In this study a 78 question questionnaire was completed

by 1154 parents, which was a 21% response rate of the approached 5600 parents (Kaaijk et al.,

2014).

Gross et al (2015) explores parental beliefs in the decision to choose not to vaccinate

their children. Some parents expressed, their desire for a personalized, patient-centered

approach to vaccination in the terms of age of the child and the timing of vaccination may be

accommodated with more precise information (Gross et al., 2015, p.7). These parents do not

agree with the overabundance of vaccines their children receive within the first year of life.

During an interview conducted by Harmsen et al. (2012) some parents had a negative

view about combination vaccinations and their lack of choice or freedom to avoid overloading

(Harmsen et al., 2012, p. 4) in a single visit. Since there was no choice to separate the vaccines,

they were refused all together.

AN INTEGRATIVE REVIEW 8

Alternative Vaccination Delivery Methods

The quantitative study, Kaaijk et al (2014), showed that parents are highly concerned

about the pain and discomfort their child experiences during vaccinations. The majority of the

participants had above average household income and were willing to pay the extra cost for

alternative vaccination delivery methods, such as a patch and jet injector.

Discussion/Implications

All of the reasons parents choose not to vaccinate have already been recognized by a

previous overview of the phenomenon of vaccine hesitancy (Dube, Laberge, Guay, Bramadat,

Roy & Bettinger, 2013). Their conceptual model of Vaccine Hesitancy includes, knowledge

and information, past experiences, perceived important of vaccination, risk perception &

mistrust, subjective norm, and religious & moral convictions (Dube et al., 2014, p. 2). This

overview provides ancillary data in support of the researchers integrative review.

Having alternate vaccine delivery methods is valuable data to bring to vaccination

developers, especially in countries where communicable disease treatment costs may supersede

the additional cost of using these methods, such as patches.

Having more children vaccinated will promote overall health for every nation.

Healthcare workers can be the childs advocate in encouraging parents to choose vaccinations.

Nurses and community outreach program employees can take the time to have a more intimate

conversation with parents to teach them about the risks for their children and others, if they

choose not to vaccinate. With respect to their decision, healthcare providers can increase

communication and information using all forms of learning styles: visual, verbal (tactile), and

auditory to best fit the needs of their community. If parents still choose not to vaccinate, they
AN INTEGRATIVE REVIEW 9

should be given additional education on how to prevent the transmission of communicable

diseases.

Limitation/Conclusion

The vast limitation to this integrative review is the researchers lack of knowledge and

expertise in the field, as well as little experience in conducting research for an integrative review.

It should be noted that, although there was no paucity or delimitation to the articles found, there

were limited quantitative studies and research that implemented an intervention to provoke a

change in parents who choose not to vaccinate.

Based on the data, there are many recommendations on strategies to be considered to

decrease the percentage of parents who choose not to vaccinate their children. The researcher

believes the next step would be to implement some of the recommendations and conduct more

research within these populations. It would be worthwhile to record if these interventions

change these parents decision on choosing not to vaccinate their children, in relation to the

researchers PICO question.

In conclusion, the researcher recommends starting the discussion on vaccinations earlier

than the postpartum/newborn period. An opportunity for discussion during the intrapartum

period may be advantageous. Parents can be given all of the necessary information they require

far enough in advance so they can make a well educated decision for their children. Having

open-ended discussion with their healthcare providers about their understanding and

misconceptions of vaccinations can help them gain a better understanding of what they are

choosing for their child.

AN INTEGRATIVE REVIEW 10

References

Delkhosh, M., Negarandeh, R., Ghasemi, E., & Rostami, H. (2014). Maternal concerns about

immunization over 0-24 month children: a qualitative research. Issues in Comprehensive

Pediatric Nursing, 37(4), 235-249. doi:10.3109/01460862.2014.951131

Dub, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., & Bettinger, J. A. (2013). Vaccine

hesitancy: An overview. Human Vaccines & Immunotherapeutics, 9(8), 17631773.

http://doi.org/10.4161/hv.24657

Gross, K., Hartmann, K., Zemp, E., & Merten, S. (2015). I know it has worked for millions of

years: the role of the natural in parental reasoning against child immunization in a

qualitative study in Switzerland. BMC Public Health, 15, 373.

http://doi.org/10.1186/s12889-015-1716-3

Harmsen, I. A., Ruiter, R. A. C., Paulussen, T. G. W., Mollema, L., Kok, G., & de Melker, H. E.

(2012). Factors That Influence Vaccination Decision-Making by Parents Who Visit an

Anthroposophical Child Welfare Center: A Focus Group Study. Advances in Preventive

Medicine, 2012, 175694. http://doi.org/10.1155/2012/175694

Harmsen, I. A., Mollema, L., Ruiter, R. A., Paulussen, T. G., de Melker, H. E., & Kok, G.

(2013). Why parents refuse childhood vaccination: a qualitative study using online focus

groups. BMC Public Health, 13, 1183. http://doi.org/10.1186/1471-2458-13-1183

Kaaijk, P., Kleijne, D. E., Knol, M. J., Harmsen, I. A., Ophorst, O. J., & Rots, N. Y. (2014).

Parents attitude toward multiple vaccinations at a single visit with alternative delivery

methods. Human Vaccines & Immunotherapeutics, 10(8), 24832489.

http://doi.org/10.4161/hv.29361

AN INTEGRATIVE REVIEW
First&Author&
(Year)/Qualifications&
Background/Problem&
Statement&
Conceptual/theoretical&
Framework%
Design/Method/Philosophical&
Underpinnings%
& % Purposeful%sampling%using%the%snowball%approach%
Sample/&Setting/Ethical&
Considerations%
% % Informed%consent,%confidentiality%and%anonymity,%and%ethical%committee%approval%
Major&Variables&Studied&(and&
their&definition),&if&
appropriate%
Measurement&Tool/Data&
Collection&Method%
Data&Analysis%
Findings/Discussion&
Appendix
Qualitative and Quantitative Article Evaluation
Gross%(2015)%%Researcher%of%Swiss%Tropical%and%Public%Health%Institute,%Switzerland%
% Researchers%wanted%to%investigate%how%parents%in%Switzerland%debate%the%use%of%vaccinations%
and%share%their%beliefs%and%attitudes%on%why%they%choose%not%to%vaccinate.%&
% Not%discussed%
% Qualitative%Study%
% SemiJstructured%interviews%
% 32%interviews%were%conducted%with%various%family%dynamics%with%children%under%the%age%of%16%
% Interviews%took%place%in%most%of%the%parents%homes%
% Parents%with%children%16%years%old%or%less%who%are%partially%immunized%%
% Parents%with%children%16%years%old%or%less%who%have%not%been%immunized%
% 60%minute%interviews%conducted%by%a%trained%interviewer%in%both%German%or%French%
% Interviews%were%recorded%and%transcribed%verbatim%and%coded%into%groups%dependent%on%the%
two%researchers%
% Demographic%Information%
% Coding%catalog%was%used%to%analyze%the%data%
% Findings%were%in%favor%of%allowing%natural%immunity%to%be%obtained%through%natural%bodily%
defenses%and%support%of%breastfeeding%that%alone%can%build%a%childs%immunity%
% Collective%concern%with%too%many%vaccines%administered%at%a%young%age%
% Mistrust%in%the%institutions%delivering%the%vaccines%and%not%so%much%in%the%vaccines%themselves%
 AN INTEGRATIVE REVIEW
Appraisal/Worth&to&practice&
First&Author&
(Year)/Qualifications&
Background/Problem&
Statement&
Conceptual/theoretical&&
Framework%
Design/Method/Philosophical&
Underpinnings%
& %
Sample/&Setting/Ethical&
Considerations%
% %
Major&Variables&Studied&(and&
their&definition),&if&appropriate%
Measurement&Tool/Data&
Collection&Method%
Data&Analysis%
Findings/Discussion&
12
% This%study%is%useful%to%understand%why%parents%choose%not%vaccinate.%%
% Provides%valuable%information%about%how%healthcare%providers%can%implement%changes%to%
support%these%parents%through%open%communication%and%detailed%discussion.%
Harmsen%(2012)%%Center%for%Infectious%Disease%Control,%National%Institute%for%Public%Health%and%the%
Environment,%The%Netherlands&
% Researchers%seek%to%explore%the%beliefs%of%parents%who%choose%not%vaccinate&
% Not%discussed%
% Qualitative%Study%using%3%focus%groups%
% SemiJstructure%openJended%questions%
Focus%groups%of%parents%who%visited%an%Anthroposophical%Child%Welfare%Center%(CWC)%
% 16%interviews%%
% Interviews%were%held%at%the%anthroposophical%CWC%
Each%focus%group%was%conducted%by%the%same%moderator%with%different%assistants%
% Informed%consent%was%obtained%and%each%participant%was%offered%a%gift%voucher%of%30%euros%with%
ethical%committee%approval.%%
% Parents%of%children%who%attended%Anthroposophical%CWCX%age%was%not%define%
% TwoJhour%interview%
% Interviews%were%recorded%and%transcribed%verbatim%%
% Analysis%was%done%using%a%thematic%approach%to%look%at%the%different%factors%that%influence%
parents%to%choose%not%to%vaccinate%their%children%
% Six%subthemes%were%determined%by%using%Nvivo%9%software%
% Coding%scheme%and%criteria%used%%
% Most%parents%said%they%need%more%information%which%could%potentially%allow%parents%to%make%
well%informed%decisions%about%vaccinations,%especially%with%the%Measles,%Mumps%and%Rubella%
(MMR)%vaccine%
% Common%theme%about%negative%views%of%combination%vaccinations%and%their%freedom%of%choice%
to%decide%which%vaccines%to%get%and%which%they%can%refuse%
 AN INTEGRATIVE REVIEW 13

Appraisal/Worth&to&practice& % The%six%themes%could%be%an%opportunity%to%conduct%quantitative%research%which%could%be%helpful%
for%the%healthcare%field%
% Quantitative%researcher%is%needed%to%help%determine%which%influencing%factors%are%most%
important%in%parents%decisions%on%choosing%not%to%vaccinate.%%
 AN INTEGRATIVE REVIEW
First&Author&
(Year)/Qualifications&
Background/Problem&
Statement&
Conceptual/theoretical&&
Framework%
Design/Method/Philosophical&
Underpinnings%
& % Participants%were%selected%on%child%vaccination%status%of%partially%vaccinated%(PV)%and%not%vaccinated%
Sample/&Setting/Ethical&
Considerations%
% % Informed%consent%was%given%by%click%a%button%online%after%having%to%read%all%of%the%study%
Major&Variables&Studied&(and&
their&definition),&if&appropriate%
Measurement&Tool/Data&
Collection&Method%
Data&Analysis%
Findings/Discussion&
14
Harmsen%(2013)%Center%for%Infectious%Disease%Control,%National%Institute%for%Public%Health%and%the%
Environment,%The%Netherlands%
% The%researchers%aim%to%to%study%the%factors%that%influence%Dutch%parents%in%their%choice%in%
partially%vaccinating%or%not%vaccinating%their%children.%&
% This%data%could%help%the%healthcare%field%create%interventions%used%to%provide%the%public%with%
the%necessary%information%to%make%the%best%decisions%for%the%children%and%the%community.&
% Not%discussed%
% Qualitative%Study%using%online%focus%groups%
% Random%sampling%of%participants%from%Praeventis,%the%Netherlands%vaccination%database%
(NV)%%
% Children%were%define%as%being%age%4%or%younger%
% 60%participants%accepted%the%invitation%to%the%online%focus%group%
% Anonymity%statements%were%given%
information.%An%incentive%of%30%euros%gift%voucher%was%offered%with%ethical%committee%
approval.%
% Parents%with%children%4%years%old%or%less%who%were%partially%vaccinated%(PV)%%
% Parents%with%children%4%years%old%or%less%who%were%not%vaccinated%(NV)%
% Participants%were%given%a%unique%login%name%and%password%
% Online%postings%were%available%5%days%during%the%week%to%allow%convenience%to%the%
participants.%Each%day%a%new%topic%was%posted%and%monitoring%of%the%discussions%were%done%
by%a%moderator%
% Data%was%analyzed%using%a%thematic%analysis.%
% The%main%themes%were%based%on%the%topics%and%questions%posted%to%the%online%forum%
% A%moderator%coded%the%data%and%analysis%was%done%for%both%PV%and%NV%participants%
% Main%themes%included:%1.%positive%and%negative%aspects%of%the%National%Immunization%Program%(NIP),%
2.%factors%influencing%parental%decision%making,%3.%informational%needs,%and%4.%new%vaccines.%
% Most%refusal%of%vaccinations%were%based%on%parental%decision%making%factors%such%as%lifestyle,%risk%
perception,%social%environment,%ect.%%
% Participants%expressed%a%lack%of%information%to%make%decisions%on%vaccine%efficacy%and%
trustworthiness.%
 AN INTEGRATIVE REVIEW 15

Appraisal/Worth&to&practice& % Using%an%online%focus%group%can%be%beneficial%in%reaching%more%participants.%
% These%results%are%helpful%in%supporting%the%NIP%to%create%more%effective%information%
interventions%
 AN INTEGRATIVE REVIEW 16

First&Author& Kaaijk%(2014)%%Researcher%for%the%Netherlands%Center%for%Infectious%Disease%Control%and%
(Year)/Qualifications& National%Institute%for%Public%Health%and%the%Environment%(RIVM),%The%Netherlands%
Background/Problem& % Researchers%aim%to%study%parents%perception%on%vaccinations%and%if%alterative%forms%of%
Statement& immunity%would%likely%encourage%full%vaccination%of%their%children.&
Conceptual/theoretical&& % Not%discussed%
Framework%
Design/Method/Philosophical& % Quantitative%Study%%
Underpinnings% % Online%Questionaire%
&
Sample/&Setting/Ethical& % 1154%parents%completed%the%online%questionnaire%
Considerations% % participants%of%both%urban%and%rural%areas%of%the%12%countries%of%the%Netherlands%were%
% randomly%selected%from%Praeventis,%a%national%database%vaccination%registration%system%
% Confidentiality%and%privacy%was%assured,%participants%were%offered%a%10%euro%voucher,%
and%ethical%board%approval%was%not%needed%accorded%to%the%Medical%Research%Involving%
Human%Subjects%Act%of%the%Netherland%(WMO)%
Major&Variables&Studied&(and& % Parents%of%children%age%12%and%under%
their&definition),&if&appropriate%

Measurement&Tool/Data& % Questionaire,78%question%survey,%scored%using%the%7%point%Likert%scale%
Collection&Method% % taking%approximately%15%minutes,%included%4%videos%
% % Demographic%Information%
Data&Analysis% % Descriptive%statistics%%mean%(M)%and%standard%deviation%(SD)%
% Comparison%of%vaccination%delivery%methods%and%amount%of%vaccinations%in%a%single%visit%
% Cross%sectional%analysis%
%
Findings/Discussion& % Findings%were%in%favor%of%alternative%vaccination%forms%such%as%a%patch%and%jetJinjector%
% Parents%would%likely%vaccinate%more%with%these%alternative%methods%because%of%less%pain%
and%discomfort%to%child%
Appraisal/Worth&to&practice& % This%is%valuable%information%for%the%healthcare%to%consider%alternative%vaccination%
methods%for%parents%who%ask%for%it.%%
% It%is%important%for%vaccinate%developers%to%take%this%into%consideration%when%creating%new%
or%improved%methods%to%provide%childhood%immunity.%
%
 AN INTEGRATIVE REVIEW 17

Delkhosh%(2014)%%Department%of%Disaster%Public%Health,%Department%of%Disaster%and%Emergency%
First&Author&
Health,%National%Institute%of%Health%Research,%Department%of%Community%Nursing,%School%of%
(Year)/Qualifications&
Nursing%&%Midwifery.%Tehran,%Iraq.%
Background/Problem& % Researchers%want%understand%the%concerns%that%mothers%have%with%immunizing%their%child.&
Statement& &
Conceptual/theoretical&&
% Not%discussed%
Framework%
Design/Method/Philosophical& % Qualitative%Exploratory%Study%
Underpinnings% % InJdepth%semiJstructured%interviews%with%key%questions%
& % Non%probability%and%purposive%sampling%method%
Sample/&Setting/Ethical&
% %
Considerations%
Major&Variables&Studied&(and&
% Mothers%of%children%24%months%or%less%who%were%not%vaccinated%
their&definition),&if&appropriate%
Measurement&Tool/Data&
Collection&Method%
% Demographic%Information%
%
%
% Analysis%was%done%using%the%conventional%content%analysis%
% Categories%and%concepts%were%created%based%on%inductive%method%
Data&Analysis%
% All%interview%were%transcribed%and%included%nonJverbal%communication%such%as%facial%
expression%
% Planning%and%monitoring%can%be%instituted%to%provide%adequate%education%to%mothers%and%
proper%education%should%be%given%to%healthcare%workers%to%be%able%to%prepare%and%support%
Findings/Discussion&
the%community%in%making%their%decisions.%
%
% This%study%provided%relevant%data%to%the%healthcare%system%to%allow%for%changes%to%be%made%
in%staff%education%to%correct%any%vaccine%misconceptions%among%mothers%who%are%are%
Appraisal/Worth&to&practice&
uncertain%or%have%negative%feelings%towards%vaccinations%along%with%education%about%the%
vaccines.%