Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis
- PMID: 34706066
- PMCID: PMC8550333
- DOI: 10.1002/14651858.CD013265.pub2
Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis
Abstract
Background: Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.
Objectives: - Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.
Search methods: We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.
Selection criteria: We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.
Data collection and analysis: We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.
Main results: We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.
Authors' conclusions: Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.
Copyright © 2021 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.
Conflict of interest statement
Sara Cooper: none known.
Bey‐Marrié Schmidt: none known.
Evanson Z Sambala: none known.
Alison Swartz: none known.
Christopher J Colvin: none known.
Natalie Leon: none known.
Charles S Wiysonge: none known.
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Update of
- doi: 10.1002/14651858.CD013265
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- Saada A, Lieu TA, Morain SR, Zikmund-Fisher BJ, Wittenberg E. Parents' choices and rationales for alternative vaccination schedules: a qualitative study. Clinical Pediatrics 2015;54(3):236-43. - PubMed
Schwarz 2009 {published data only}
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- Schwarz NG, Gysels M, Pell C, Gabor J, Schlie M, Issifou S, et al. Reasons for non-adherence to vaccination at mother and child care clinics (MCCs) in Lambarene, Gabon. Vaccine 2009;27(39):5371-5. - PubMed
Sensarma 2015 {published data only}
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- Sensarma P, Bhandari S, Kutty VR. Barriers to immunization among children of HIV-infected mothers in Kolkata, India: a qualitative study. Asia-Pacific Journal of Public Health 2015;27(2):NP1362-71. - PubMed
Shefer 1998 {published data only}
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- Shefer A, Mezoff J, Caspari D, Bolton M, Herrick P. What mothers in the Women, Infants, and Children (WIC) program feel about WIC and immunization linkage activities. A summary of focus groups in Wisconsin. Archives of Pediatrics & Adolescent Medicine 1998;152(1):65-70. - PubMed
Shui 2005 {published data only}
Sjogren 2017 {published data only}
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- Sjogren E, Ask LS, Ortqvist A, Asp M. Parental conceptions of the rotavirus vaccine during implementation in Stockholm: a phenomenographic study. Journal of Child Health Care 2017;21(4):476-87. - PubMed
Smith 2017 {published data only}
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- Newton P, Smith DM. Factors influencing uptake of measles, mumps and rubella (MMR) immunization in site-dwelling Gypsy, Roma and Traveller (G&T) communities: a qualitative study of G&T parents' beliefs and experiences. Child: Care, Health & Development 2017;43(4):504-10. - PubMed
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- Smith D, Newton P. Structural barriers to measles, mumps and rubella (MMR) immunisation uptake in Gypsy, Roma and Traveller communities in the United Kingdom. Critical Public Health 2017;27(2):238-47.
Sobo 2016 {published data only}
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- Sobo EJ, Huhn A, Sannwald A, Thurman L. Information curation among vaccine cautious parents: Web 2.0, pinterest thinking, and pediatric vaccination choice. Medical Anthropology 2016a;35(6):529-46. - PubMed
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- Sobo EJ. Theorizing (vaccine) refusal: through the looking glass. Cultural Anthropology 2016b;31(3):342-50.
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- Sobo EJ. What is herd immunity, and how does it relate to pediatric vaccination uptake? US parent perspectives. Social Science & Medicine 2016c;165:187-95. - PubMed
Stamidis 2019 {published data only}
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- Stamidis KV, Bologna L, Bisrat F, Tadesse T, Tessema F, Kang E. Trust, communication, and community networks: how the CORE Group Polio project community volunteers led the fight against polio in Ethiopia's most at-risk areas. American Journal of Tropical Medicine and Hygiene 2019;101(4 Suppl):59-67. - PMC - PubMed
Swaney 2018 {published data only}
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- Swaney SE, Burns S. Exploring reasons for vaccine-hesitancy among higher-SES parents in Perth, Western Australia. Health Promotion Journal of Australia 2018;09:09. - PubMed
Sychareun 2019 {published data only}
Syiroj 2019 {published data only}
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- Syiroj ATR, Pardosi JF, Heywood AE. Exploring parents' reasons for incomplete childhood immunisation in Indonesia. Vaccine 2019;37(43):6486-93. - PubMed
Tabana 2016 {published data only}
Tadesse 2009 {published data only}
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- Tadesse H, Deribew A, Woldie M. Explorative assessment of factors affecting child immunization in Wonago district, Gedeo zone, South Ethiopia. Archives of Medical Science 2009;5(2):233-40.
Tadesse 2017 {published data only}
Tarrant 2003 {published data only}
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- Tarrant M, Gregory D. Exploring childhood immunization uptake with First Nations mothers in north-western Ontario, Canada. Journal of Advanced Nursing 2003;41(1):63-72. - PubMed
Tarrant 2008 {published data only}
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- Tarrant M, Thomson N. Secrets to success: a qualitative study of perceptions of childhood immunisations in a highly immunised population. Journal of Paediatrics & Child Health 2008;44(10):541-7. - PubMed
Tickner 2007 {published data only}
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- Tickner S, Leman PJ, Woodcock A. 'It's just the normal thing to do': exploring parental decision-making about the 'five-in-one' vaccine. Vaccine 2007;25(42):7399-409. - PubMed
Tickner 2010 {published data only}
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- Tickner S, Leman PJ, Woodcock A. Parents' views about pre-school immunization: an interview study in southern England. Child: Care, Health & Development 2010;36(2):190-7. - PubMed
Tomlinson 2013 {published data only}
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- Tomlinson N, Redwood S. Health beliefs about pre-school immunisation. Diversity and Equality in Health and Care 2013;10(2):101-13.
Topuzoglu 2007 {published data only}
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- Topuzoglu A, Ay P, Hidiroglu S, Gurbuz Y. The barriers against childhood immunizations: a qualitative research among socio-economically disadvantaged mothers. European Journal of Public Health 2007;17(4):348-52. - PubMed
Vandenberg 2015 {published data only}
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- Vandenberg SY, Kulig JC. Immunization rejection in southern Alberta: a comparison of the perspectives of mothers and health professionals. Canadian Journal of Nursing Research 2015;47(2):81-96. - PubMed
Varghese 2013 {published data only}
Wang 2015 {published data only}
Ward 2017 {published data only}
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- Attwell K, Leask J, Meyer SB, Rokkas P, Ward P. Vaccine rejecting parents' engagement with expert systems that inform vaccination programs. Journal of Bioethical Inquiry 2017;14(1):65-76. - PubMed
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- Ward PR, Attwell K, Meyer SB, Rokkas P, Leask J. Risk, responsibility and negative responses: a qualitative study of parental trust in childhood vaccinations. Journal of Risk Research 2018;21(9):1117-30.
White 1995 {published data only}
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- White GE, Thomson AN. 'As every good mother should.' Childhood immunization in New Zealand: a qualitative study. Health & Social Care in the Community 1995;3(2):73-82.
Widayanti 2020 {published data only}
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- Widayanti AW, Norris P, Green JA, Heydon S. Is expanding service through an outreach programme enough to improve immunisation uptake? A qualitative study in Indonesia. Global Public Health 2020;15(8):1168-81. - PubMed
Wilson 2000 {published data only}
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- Wilson T. Factors influencing the immunization status of children in a rural setting. Journal of Pediatric Health Care 2000;14(3):117-21. - PubMed
Wilson 2008 {published data only}
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- Wilson K, Barakat M, Vohra S, Ritvo P, Boon H. Parental views on pediatric vaccination: the impact of competing advocacy coalitions. Public Understanding of Science 2008;17(2):231-43. - PubMed
Zamir 2017 {published data only}
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- Zamir CS, Israeli A. Knowledge, attitudes and perceptions about routine childhood vaccinations among Jewish ultra-orthodox mothers residing in communities with low vaccination coverage in the Jerusalem District. Maternal & Child Health Journal 2017;21(5):1010-7. - PubMed
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Conis 2014 {published data only}
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Das 2000 {published data only}
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Demolis 2018 {published data only}
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Feldman‐Savelsberg 2000 {published data only}
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Feldman‐Savelsberg 2005 {published data only}
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Fourn 2009 {published data only}
Gardner 2010b {published data only}
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Gazmararian 2010 {published data only}
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Gesser‐Edelsburg 2016 {published data only}
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- Gesser-Edelsburg A, Shir-Raz Y, Green MS. Why do parents who usually vaccinate their children hesitate or refuse? General good vs. individual risk. Journal of Risk Research 2016;19(4):405-24.
Ghinai 2013 {published data only}
Godoy‐Ramirez 2019 {published data only}
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- Godoy-Ramirez K, Bystrom E, Lindstrand A, Butler R, Ascher H, Kulane A. Exploring childhood immunization among undocumented migrants in Sweden - following qualitative study and the World Health Organizations Guide to Tailoring Immunization Programmes (TIP). Public Health 2019;171:97-105. - PubMed
Gottlieb 2016 {published data only}
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- Gottlieb SD. Vaccine resistances reconsidered: vaccine skeptics and the Jenny McCarthy effect. BioSocieties 2016;11(2):152-74.
Gross 2015 {published data only}
Habib 2017 {published data only}
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- Habib MA, Soofi SB, Ali N, Hussain I, Tabassum F, Suhag Z, et al. Knowledge and perceptions of polio and polio immunization in polio high-risk areas of Pakistan. Journal of Public Health Policy 2017;38(1):16-36. - PubMed
Helle 2001 {published data only}
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- Helle S. Infusions of health: the popularity of vaccinations among Bissa in Burkina Faso. Anthropology and Medicine 2001;8(2/3):163-75.
Helps 2019 {published data only}
Hilton 2007b {published data only}
Hobson‐West 2003 {published data only}
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- Hobson-West P. Understanding vaccination resistance: moving beyond risk. Health, Risk & Society 2003;5(3):273-83.
Hobson‐West 2004 {published data only}
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- Hobson-West P. The construction of lay resistance to vaccination. In: Shaw I, Kauppinen K, editors(s). Constructions of Health and Illness. London (UK): Routledge, 2004:89-106.
Hobson‐West 2007 {published data only}
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- Hobson-West P. 'Trusting blindly can be the biggest risk of all': organised resistance to childhood vaccination in the UK. Sociology of Health & Illness 2007;29(2):198-215. - PubMed
Holler 2012 {published data only}
Holte 2012 {published data only}
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- Holte JH, Mæstad O, Jani JV. The decision to vaccinate a child: an economic perspective from southern Malawi. Social Science & Medicine 2012;75(2):384. - PubMed
Ishita 2000 {published data only}
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Jackson 2017b {published data only}
Jalloh 2019 {published data only}
Jegede 2007 {published data only}
Johnson 2013 {published data only}
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Judith 1983 {published data only}
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Kennedy 2008 {published data only}
Kennedy 2014 {published data only}
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Keshet 2018 {published data only}
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Kitta 2012 {published data only}
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Kofoed 1992 {published data only}
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Kowal 2015 {published data only}
Krishnamoorthy 2019 {published data only}
Kulig 2002 {published data only}
Largent 2012 {published data only}
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Larson 2018 {published data only}
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Lasseter 2020 {published data only}
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Lawrence 2014 {published data only}
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Leask 2006b {published data only}
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Lee 2011 {published data only}
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Lester 2000 {published data only}
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Letley 2018 {published data only}
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Lind 2014 {published data only}
Lind 2015 {published data only}
Lindegger 2007 {published data only}
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Logullo 2008 {published data only}
Luthy 2012 {published data only}
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Luthy 2013 {published data only}
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Machekanyanga 2017 {published data only}
Mack 1999 {published data only}
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Maryam 2007 {published data only}
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Maya 2016 {published data only}
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McCoy 2019 {published data only}
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McDonald 2019 {published data only}
McGranahan 2016 {published data only}
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McHale 2016 {published data only}
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McIntosh 2016 {published data only}
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Murakami 2014 {published data only}
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Namuigi 2005 {published data only}
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Navin 2016 {published data only}
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- Navin M. Values and Vaccine Refusal: Hard Questions in Ethics, Epistemology, and Health Care. New York (NY): Routledge, 2016.
Newton 2006 {published data only}
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- Newton S, Chantler T, Diggle L, Yu L, McCarthy N, Moxon R, et al. Parental acceptability of a pneumococcal conjugate vaccine in the UK childhood immunisation schedule. Primary Health Care 2006;16(8):34-9.
Nichter 1995 {published data only}
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Offit 2011 {published data only}
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- Offit PA. Deadly Choices: How the Anti-Vaccine Movement Threatens Us All. New York (NY): Basic Books, 2011.
Oku 2017 {published data only}
Omotara 2012 {published data only}
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- Omotara BF, Okujagu T. Assessment of knowledge, attitude and practice of stakeholders towards immunization in Borno State, Nigeria: a qualitative approach. Journal of Community Medicine & Health Education for Health 2012;2(9):181.
Onnela 2016 {published data only}
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Oude 2016 {published data only}
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Patel 2007 {published data only}
Paterson 2018b {published data only}
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Peprah 2016 {published data only}
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Plumridge 2008 {published data only}
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Pugliese‐Garcia 2018 {published data only}
Raithatha 2003 {published data only}
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Rodrigues 2014 {published data only}
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Rodriguez 2016 {published data only}
Rozbroj 2020 {published data only}
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Sampson 2011 {published data only}
Schaetti 2012 {published data only}
Schoeppe 2017 {published data only}
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Shahbari 2020 {published data only}
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