This report presents findings from a survey of 198 pediatric healthcare professionals that examines why children go unvaccinated in mixed-income communities. It distinguishes outright vaccination refusal driven by mistrust, sociocultural beliefs, and low health literacy from adherence issues such as missed appointments, which stem from logistical and economic barriers. The report closes with targeted recommendations for healthcare systems and practices to improve equity.
This report summarizes the findings of a survey conducted in October/November 2024, focusing on childhood vaccination equity and healthcare professional experiences.
The survey, a collaboration between the Excellence in Pediatrics Institute (EIPI) and Pfizer, aimed to explore the complexities of vaccination hesitancy and low uptake rates, particularly within communities of mixed socioeconomic backgrounds.
The primary goal is to identify the key factors contributing to vaccination disparities and develop targeted public health strategies to improve adherence, leveraging different influencing factors in each case. Sociocultural factors, educational barriers, and authority mistrust drive the outright refusal of vaccination, while logistical failures and economic factors contribute most to adherence issues.
Despite significant advancements in healthcare, including vaccine development and widespread availability, vaccination uptake and coverage rates across Europe continue to fall short of established targets. This discrepancy is particularly evident in marginalized communities, such as the traveling community and newly arrived immigrants. Due to various social, economic, and logistical barriers, these groups often exist on the periphery of national healthcare systems.
While these issues are widely recognized and have been the focus of numerous public health initiatives, another critical segment of the population that significantly contributes to low vaccination rates remains unexplored.
In communities with mixed socioeconomic backgrounds, effectively underserved individuals pose a unique challenge to public health efforts. These individuals often do not conform to the general health behaviors observed in their communities, including adherence to recommended vaccination schedules.
Their decisions to skip vaccinations are influenced by a complex interplay of factors not solely defined by their marginal status. They are deeply intertwined with the dynamics of their immediate social and economic environments.
The reasons behind their health choices may include limited access to healthcare services, varying levels of trust in medical advice depending on their information sources, and the socioeconomic and educational disparities within their communities. Whether they reside in urban, suburban, or rural areas, the accessibility and convenience of healthcare services can differ dramatically, not just between different types of communities but also within the same community among individuals of different socioeconomic strata.
Addressing these disparities requires a nuanced understanding of how localized factors influence health behaviors. Effective public health strategies must go beyond broad coverage targets and address the specific needs of these under-vaccinated groups. Engaging in grassroots efforts to reach these individuals where they are, understanding their unique perspectives, and tailoring interventions to their particular circumstances could substantially enhance vaccination rates. This approach acknowledges the diversity of community experiences. It seeks to reduce health inequities by ensuring all individuals have equitable access to vital healthcare services regardless of their socioeconomic status or community type.
We employed a dual-method survey approach to gather comprehensive insights into the landscape of vaccination equitable access. First, an online survey was made available for a duration of 35 days, targeting child healthcare professionals directly involved in patient care. This study segment aimed to collect firsthand data on the experiences, challenges, and perceptions of those working on the frontlines of pediatric healthcare.
Simultaneously, we distributed targeted mapping questionnaires to leading experts
and academics across multiple countries. Due to their extensive experience and high-level understanding of national healthcare dynamics, these individuals provided invaluable contextual analysis. Their role was to offer a macro perspective on pediatric healthcare policies, vaccination strategies, and systemic challenges affecting immunization uptake. More importantly, they reported on behalf of their local medical communities, offering aggregated insights that complemented the firsthand accounts gathered from practicing clinicians.
The survey aimed to capture the perspectives of pediatric healthcare professionals actively involved in grassroots efforts to improve vaccination rates engaged in primary healthcare settings and private practices.
These professionals are at the frontline of community health networks, directly engaging with families from various socioeconomic backgrounds. They provide critical insights into the factors that influence their health decisions and an understanding of parental decision-making processes and the dynamics within their local communities.
Through regular interactions with parents, frontline physicians are best positioned to identify specific challenges and barriers to vaccination uptake. This makes their perspectives invaluable for developing targeted, community-focused interventions.
The survey aimed to deliver a comprehensive and nuanced understanding of the factors impacting pediatric vaccination rates. Insights from these key healthcare professionals will be instrumental in designing effective public health strategies to enhance vaccination equity and coverage.
Most respondents identified as pediatricians (83.96%), working primarily in private practices (48.81%) or hospitals (44.05%).
59.14% of the participants work in urban areas with mixed socioeconomic backgrounds; thus, their experiences relate directly to the issues that are the focus of the study.
The survey results highlight that low vaccination rates are not solely confined to traditionally marginalized communities. A significant problem lies within communities of mixed socioeconomic backgrounds, where specific individuals or subgroups do not follow recommended vaccination schedules. These individuals are described as “effectively underserved within their own environments.”
This points to the fact that addressing disparities is not a simple matter of targeting entire communities but also requires consideration of variations within communities and sub-populations. A complex interplay of factors influences their decisions to skip vaccinations and is deeply intertwined with the dynamics of their immediate social and economic environments.
Furthermore, the survey results indicate that assuming all unvaccinated individuals refuse vaccination by conviction is oversimplified. This often leads us to overlook the fact that a significant portion of the unvaccinated population faces circumstantial barriers rather than ideological opposition. A multitude of factors and systemic failures are responsible for this phenomenon.
Parental decisions regarding child vaccination are often influenced by a complex interplay of sociocultural, educational, economic, and trust-related factors. To effectively address barriers to vaccination, it is essential to distinguish between outright refusal and adherence issues, such as missed appointments.
The survey asked respondents to rate the attribution of factors contributing to vaccination refusal and adherence separately using a number scale, with 1 being the most influential factor.
72.95% of respondents accounted for parental decisions being the most important factor in vaccination refusal (5.23 weighted average), and 70.83% for missed appointments and adherence issues (5.18 weighted averages).
Healthcare system logistical and communication failures were rated as the second most influential factor for adherence issues (4.45 weighted average). They have also been rated as the second most important factor for vaccine refusal, but with a significantly lower rating (3.82 weighted average).
The survey further investigated the factors impacting most parental decisions not to vaccinate their children.
Sociocultural factors (e.g., beliefs, language barriers) were significantly influential, with 67.94% rating them as 1 or 2 (3.73 weighted average).
Educational factors (e.g., health literacy) were the second most important factor (3.38 weighted average), followed by mistrust of authority (e.g., misinformation, peer influence) (3.33 weighted average).
Based on the survey results, parental decisions are the most critical factor in vaccination refusal and adherence issues, but with different drivers in each case. Sociocultural factors, educational barriers, and authority mistrust drive the outright refusal of vaccination, while logistical failures and economic factors contribute most to adherence issues.
The survey further analyzed the factors influencing parental decisions not to vaccinate their children.
Parental refusal is often deeply rooted in sociocultural beliefs and mistrust. The most significant contributors include:
Access to digital/online information (4.51 weighted average) and the perception that limited social interactions reduce health risks (4.19 weighted average) were also considered critical sociocultural factors.
37% of the participants stated mistrust of authorities and healthcare recommendations (5.37 weighted average) as the most influential sociocultural factor driving skepticism about vaccines. The second driver was the reliance on traditional community experiences and advice from family or local networks over physicians (rated 1 by 29.59% of responders, 5.26 weighted average).
Language barriers and difficulties understanding medical advice, even if rated lower than the other sociocultural factors (3.38 weighted average), exacerbate the difficulty of navigating and trusting the healthcare system and its providers.
“The distinction is between misinformation, which can be accidental, and disinformation, which is usually malicious, sometimes for personal, economic, or political reasons. But the impact is often quite similar. It is so impactful because it answers a question we have in our minds. We're all potentially vulnerable to misinformation on all fronts. As an exercise, you might think about the things you've believed in the past and changed your mind about or realized were a conspiracy theory or just accidentally misinformed. And the appeal is typically that the explanation feels true. It's usually quite simple. Repetition or hearing the same thing from different sources reinforces the impact and believability of a rumor or some misinformation online.” Comment made during the 9th LifeCourse Summit in November 2024
Lack of adequate knowledge and skills to navigate healthcare systems or evaluate vaccine information contributes to parental refusal:
51.25% of respondents rated inadequate education affecting informed health decisions (3.24 weighted average) as the most critical education-related factor in parental refusal, followed by challenges in evaluating online information leading to misinformation susceptibility (rated second with 2.18 weighted average).
Low health literacy and understanding of medical terms (2.68 weighted average) increase susceptibility to misinformation, creating challenges in communicating with healthcare providers and navigating the healthcare system.
Authority mistrust emerges as a defining factor in vaccination refusal:
Personal health beliefs and autonomy (rated 1 or 2 by 56% of the participants, 5.79 weighted average) lead many parents to favor natural solutions or reject medical interventions altogether.
Historical grievances (5.00 weighted average) and perceived pharmaceutical influence (5.55 weighted average) were reported as important factors contributing to mistrust.
Failure of authorities to fulfill promises or efficiently manage resources (4.97 weighted average) and perceived injustices and discrimination by authorities related to factors like race or class (4.91 weighted average) amplify mistrust.
Political polarization is a significant parameter to consider (4.87 weighted average) since, in polarized settings, trust in authorities often depends on political alignment, causing distrust among those with differing views about vaccination programs, particularly in tight-knit communities.
“For most people, it's not that they're against vaccines; it's just a failure to make it happen. They live in an apartment 15 floors up, they've got three children under five, they've got a job, they don't know when the appointment is, they miss it, they don't know how to reschedule it.”
“In my region, it's normal for children to be vaccinated during routine visits. However, families must go to a special vaccination center in other areas. The difference in convenience is stark and correlates with lower vaccination rates.” As noted during the 9th LifeCourse Summit
Participants noted that logistical and communication failures within the healthcare system significantly contributed to adherence issues, with a weighted average score of 4.45.
Economic factors also play a crucial role in parental decisions, influencing behaviors such as deviating from national vaccination schedules, missing appointments, and skipping follow-up doses. These decisions are generally not due to outright vaccination refusal but arise from everyday challenges and circumstances the healthcare system fails to address.
Expressly, 63.38% of respondents (rated 1 or 2) indicated that economic burdens overshadow health considerations, as reflected by a weighted average of 4.65. Immediate financial needs are often prioritized over long-term health benefits.
In addition, work schedules and difficulties obtaining time off—evidenced by 35.29% of respondents rating these challenges as 1 and a weighted average of 4.62—emerge as significant barriers, particularly for parents in precarious employment situations.
Concerns regarding vaccine costs, limited awareness of free vaccination options (weighted average of 4.04), and persistent health insurance issues (weighted average of 3.01) highlight a failure by the healthcare system to effectively communicate available services and assist this population in navigating the system.
Finally, transportation challenges, which received a weighted average of 2.97, further hinder access to appointments, especially for families residing in suburban and rural areas.
The comparative analysis reveals that while both vaccination refusal and adherence issues stem from parental decision-making, the underlying causes diverge significantly. Understanding the distinctions between refusal and adherence is essential for designing effective public health interventions.
For vaccination refusal, the primary drivers are deeply held beliefs and mistrust. Parents often base their decisions on sociocultural influences, such as reliance on traditional community advice, skepticism toward authorities, and educational challenges like low health literacy. This results in a persistent wariness of medical recommendations, making refusal more about ideological conviction and less about practical obstacles.
In contrast, adherence issues—such as missed appointments—are mainly influenced by systemic and logistical challenges. Economic constraints, rigid work schedules, and healthcare system inefficiencies (including communication failures) dominate their decisions. Parents facing these issues are not necessarily opposed to vaccination; they encounter practical barriers preventing them from following vaccination schedules.
Still, the findings underscore that vaccination refusal is a complex interplay of deeply held convictions fueled by sociocultural influences and educational challenges. These interconnected factors reveal that addressing vaccination refusal requires an approach that improves education and communication about vaccines, actively works to rebuild trust, and acknowledges the nuanced cultural and historical contexts influencing parental decisions.
Addressing vaccination refusal requires multifaceted interventions that rebuild trust and improve educational outreach. Improving adherence demands operational enhancements in healthcare delivery and support mechanisms that reduce logistical and economic burdens.
The survey questions in this section aimed to gain insights into how healthcare systems influence vaccination refusal and adherence issues, categorized by the distinct challenges and factors at play.
Survey participants unanimously agreed that all community members have equal access to vaccination (76.77%), that vaccines from the national immunization schedule are provided free of charge (95.96%), and that vaccines are offered to all children regardless of their parent's insurance status (98.99%).
These results, when viewed alongside previously reported parental concerns regarding vaccine costs and health insurance issues, highlight a failure by the healthcare system to communicate the services and benefits it offers effectively and
to assist this population in navigating the system. Nevertheless, 23.23% of respondents indicated that not all community members have equal access to vaccination services, suggesting disparities in outreach and healthcare infrastructure.
Additionally, respondents reported that outreach to parents of unvaccinated children is inconsistent: 7.22% reported no outreach, 20.62% reported rare outreach efforts, and 39.18% reported occasional outreach, while only 32.99% reported frequent outreach.
An examination of the educational role of healthcare systems revealed several gaps consistent with previous findings:
Tailored communication materials for specific sociocultural communities are absent in 37.76% of cases, limiting the system's ability to address cultural nuances.
Limited prenatal vaccine education (38.78%) deprives parents of early, evidence-based information.
Ineffective vaccine communication training was noted, with 45.26% of healthcare providers lacking adequate training in effectively communicating about vaccines, which reduces their ability to counteract misinformation and address parental concerns.
Participants confirmed that 83.84% of their healthcare systems maintain records of the population's vaccination status, yet significant gaps exist in utilizing these data for targeted interventions.
60.82% of respondents reported not having access to local data on unvaccinated individuals, even though 65.63% indicated that the local healthcare authority maintains such data.
75.00% confirmed they collect and record patient vaccination status data during visits for other health reasons.
In conclusion, this section reveals a significant disconnect between the theoretical availability of vaccination services and the practical
challenges experienced by parents. Although most respondents believe that vaccines are free, universally accessible, and provided regardless of insurance status, these assurances contrast sharply with persistent parental concerns regarding vaccine costs and insurance complications. Key findings include disparities in access, inconsistent outreach, critical educational shortcomings, and data utilization issues, all of which contribute to significant barriers to achieving adequate vaccination adherence—even in a context where services are theoretically accessible and free.
The survey examined various factors to understand how primary care practices address vaccination refusal and adherence issues.
“Some earlier vaccinations should be happening elsewhere besides a GP surgery. Wouldn't they feel safer in midwife services, where babies have health checks and only babies go?” Comment made during the 9th LifeCourse Summit
Limited Non-Standard Working Hours: Only 23.60% of providers frequently offer after-hours appointments, which leaves many parents unable to attend due to rigid work schedules.
Infrequent Walk-In or Same-Day Appointments: Only 39.33% of providers occasionally offer walk-in or same-day appointments, posing challenges for parents who cannot commit to scheduled appointments because of their occupational constraints.
“Social media has turbocharged the spread of misinformation, and anti-vaccine groups have been very good at reaching hesitant or undecided people who don't think about vaccination until they're invited to bring their child or a parent or themselves to a clinic to be vaccinated. Vaccine advocates are more likely to talk to one another, and traditionally, in this context, we haven't been great at using social platforms, which are mostly cheap and, in some cases, free. It improved a little during the pandemic, but some of the lessons of the pandemic have been learned, but some of them have faded away, which is quite disappointing.” As noted during the 9th LifeCourse Summit in November 2024
Inadequate Reminders and Follow-Ups: Many providers do not consistently send appointment reminders or follow-ups—13.64% never send reminders, 14.77% rarely do, and 30.68% only occasionally do so.
Lack of Tailored Communication: For 36.36% of respondents, the absence of customized communication regarding the benefits and risks of childhood vaccination further exacerbates accessibility challenges for socioculturally diverse families.
Vaccine Safety and Efficacy: Parents frequently express concerns about vaccine safety, side effects, and necessity, with 83.33% of providers encountering these issues at least sometimes.
Reliance on Non-Medical Information: 73.33% of respondents reported that parents often seek information from non-medical sources before discussing vaccination with their physician.
Competing Priorities: 60.67% observed that, among very low-income families, other issues take precedence over preventive measures like vaccination.
Misinformation Challenges: Misinformation remains a significant hurdle, with 78.41% of providers frequently spending time debunking myths and countering anti-vaccine narratives.
Success in Influencing Decisions: Despite parental concerns, providers reported 38.89% often and 42.22% sometimes convincing parents to vaccinate their children, highlighting the critical role of effective physician communication.
Proactive Engagement: Moreover, 88.89% of providers stated that they often or sometimes discuss vaccination with parents during visits for unrelated health issues.
These findings underscore that while primary care providers play a critical role in promoting vaccination, significant challenges remain. Limited accessibility—through rigid appointment schedules and infrequent walk-in opportunities—combined with communication deficiencies, such as inconsistent reminders and a lack of tailored messaging, contribute to ongoing barriers.
Additionally, providers face persistent parental concerns driven by misinformation and competing priorities, which complicate vaccine discussions. Despite these obstacles, healthcare practices' proactive engagement, as evidenced by their success in influencing vaccination decisions during routine visits, highlights a promising opportunity to strengthen outreach and improve adherence.
Addressing these gaps through enhanced accessibility, targeted communication, and consistent patient education is essential for bolstering vaccination rates and safeguarding public health.
The survey provided valuable insights into the complex factors influencing vaccination decisions and the challenges healthcare professionals face. Public health strategies must go beyond a simple blanket approach and consider individual circumstances. A multifaceted approach is needed to address outright vaccination refusal and adherence issues to improve vaccination rates and equity.
“Vaccination in schools has made a massive difference to me as a parent who works full time in a really busy job. I just had to click some buttons, and then they had it in school, and I didn't have to argue with them.” Comment made at the 9th LifeCourse Summit in November 2024
Tailored Messaging:
Provider Communication Training:
“As a citizen's organization, we offer open days in which we open our office or meet citizens in the public square, but together with the general practitioner, pharmacist, and expert, to provide information and have the time to discuss and talk with the citizens.” As noted during the 9th LifeCourse Summit
“I work with families in temporary accommodation and the figures show that the number of children in such situations keeps rising. These are families that, for a host of reasons, remain hidden from mainstream services. If we don't adapt our outreach and tailor our communication, these children remain at high risk.” As noted during the 9th LifeCourse Summit
Proactive Engagement:
Flexible Scheduling:
Enhanced Outreach Infrastructure:
Data Collection and Utilization:
Monitoring and Evaluation:
“Hyper-local campaigns are becoming more common now. They are led by influencers online and offline in communities smaller than a country, smaller than a region, down to communities, down to a town. And when we talk about communities online, these are sometimes not geographic communities.” As noted during the 9th LifeCourse Summit
“Why shouldn't we leverage community pharmacies as vaccination pathways? Because they are highly skilled and trained healthcare professionals and because of pharmacies' accessibility and convenience…Pharmacists are well known to the community and know their community well; they understand where there might be some hesitancy or concerns about vaccines, and they can address those with information since they are widely accepted and trusted by the public.” Comment made at the 9th LifeCourse Summit
Financial Support and Incentives:
Transportation Solutions:
Building Trust:
Early Education Initiatives:
Integrated Public Health Strategies:
Resource Allocation:
By implementing these interventions, public health officials and healthcare providers can more effectively bridge the gap between theoretical access to vaccines and parents' real-world challenges. Tailoring approaches to diverse communities' specific needs and improving communication and operational systems are essential steps toward achieving higher vaccination equity and better overall public health outcomes.
This report summarizes the findings of a survey conducted in October/November 2024, focusing on healthcare professionals' experiences in childhood vaccination equity. The survey aimed to explore the complexities of vaccination hesitancy and low uptake rates, particularly within communities of mixed socio-economic backgrounds. The survey results were discussed at the 9th LifeCourse Immunization Summit in Barcelona by a diverse panel of academics, experts, and representatives from various organizations and institutions.
All expert quotes referenced in the report were made during the expert discussions during the 9th LifeCourse Summit in Barcelona, Spain, in November 2024.
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This report was developed in a collaboration between the Excellence in Pediatrics Institute (EIPI) and Pfizer.
