Why Unvaccinated Children are Not Always a Matter of Simple Parental Choice

Decreasing vaccination rates, which can lead to outbreaks of preventable diseases, greatly concern public health officials and policymakers. Discussions of this issue, however, have rested on the assumption that parental choice is to blame for unvaccinated or incompletely vaccinated children. But family circumstances and the availability and cost of vaccines are important, too.

When the 2015 Disneyland measles epidemic infected over 100 children, for example, the backlash focused on parental choice. In the aftermath of the outbreak, social media posters brandished derogatory labels for parents who decided not to vaccinate their children, going so far as to suggest that such parents should be sued or put in jail. Editorials depicted parents with unvaccinated children as misinformed, unintelligent, and irresponsible people who risk their children’s safety and the safety of their entire communities. Health care providers started refusing to see unvaccinated children, and lawmakers proposed new legislation to limit parental choice. In California, such efforts led to Senate Bill 277, which requires parents to vaccinate their children unless doctors provide a medical excuse. Previously, Californians had been able to opt out of vaccination for religious reasons or because of personal preferences.

Overlooked in this focus on parental choice is the importance of circumstances such as where and when vaccines are available and at what cost. Apart from parental choice, issues of availability and cost explain why many children go unvaccinated — not just in developing nations, where the importance of access and cost is acknowledged, but also in developed countries like the United States. Understanding and addressing the structures that prevent people from opting in to vaccination may be just as important as arguing about why some parents opt out of vaccination regimens. In relation to the measles vaccine specifically, a recent study by Philip Smith and colleagues found that 74.6 percent of unvaccinated children in the United States went without this vaccination for reasons other than parents’ beliefs. 

Structural Barriers and Competing Concerns 

Multiple studies have shown that U.S. vaccination rates are lowest among children living in poverty. Parental education and race, as well as family residence in either inner cities or rural areas, also reduce rates of childhood vaccination. Qualitative studies highlighting the experiences of poor parents whose children are not completely vaccinated suggest two primary issues: structural barriers that prevent parents from getting access to vaccination, and competing concerns that prevent parents from placing a priority on vaccination. 

Key structural barriers include the inability of parents to pay for vaccines, a lack of reliable transportation to and from health clinics, long lines at health clinics, and a lack of flexibility in scheduling clinic appointments. Obviously, these problems can be especially acute for parents who work multiple jobs or have limited abilities to get time off from work. 

• In my own research on vaccination, I found that such barriers matter even for parents who would opt for vaccination given the choice. Lindsay, for example, explained that “I pay almost $475 a month for private insurance but only $400 of well-baby visits were covered in my child’s first year. I think that got used up by his four month visit, so after that we skipped his well-child checks until the next calendar year so he didn’t get any vaccinations during that time."

• Another mother, Trudy, had just moved to Seattle a few months before our interview. Her husband had lost his job in a neighboring state, so Trudy, her husband, and their three children moved Washington to live with her parents. The family had hoped that Trudy’s husband would be able to find work but he had been unsuccessful. At the time of our interview, Trudy’s oldest child, who was three, was completely vaccinated, but her eight-month-old twins were completely unvaccinated. Trudy cried as she explained that since her husband was out of work, they had no insurance and no money to pay for the vaccines. Due to her white, middle-class, and generally privileged background, Trudy was unaware of the safety net programs that could have allowed her children to receive medical care, including vaccinations, at no cost.

Other, more subtle factors can also discourage vaccination, as when parents live in circumstances where competing concerns – like dealing with neighborhood gang violence or hunger – seem more pressing to parents than arranging vaccinations. If, for example, parents are worried about feeding their children on a daily basis, they will be less likely to make the effort to take their healthy children to a clinic to receive vaccines. In consequence, vaccination rates among children in low-income and otherwise-disadvantaged groups remain low.

What Can be Done

Legislators, community activists, and others interested in improving vaccination rates should move beyond urging parents to make the right choices to consider, as well, the following factors: 

• Whether vaccines are available, at an affordable cost, to all community members.

• Whether there are enough public vaccination clinics open during days and at times that are accessible to meet the needs of various community members, as well as convenient modes of transportation to these clinics.

• Whether public information about programs is properly targeted to reach parents who might not know about them.

• Whether vaccines are offered in ways (and at times and places) that would make it easy for parents to access these in spite of competing concerns about child health and safety. 

Unless these issues are considered and addressed there will be limits to further improving vaccination rates across the United States. New policies like the California law that focus on parental choice can make a difference, but only in the minority of cases where non-vaccination is actually due to parental decisions. The difficult circumstances that prevent families from vaccinating must be earnestly addressed if communities truly want to improve vaccine coverage.