Why children are not vaccinated: a review of the grey literature

The review aimed to identify reasons why eligible children had incomplete or no vaccinations. The main reasons for under-vaccination were related to immunization services and to parental knowledge and attitudes. The review analyzed 126 documents from the global grey literature, which included reports and other documents from international organizations, journal articles, field project reports, and other types of studies. The documents were from various regions, including Africa, Asia, Latin America, the Middle East, and Europe. The countries with the most projects included India, Kenya, and Bangladesh. The review found that service factors and parental attitudes and knowledge emerged as the most important categories. The most frequently cited factors were distance/travel conditions/access, poor health staff motivation and performance/competence, and lack of resources/logistics. Distance/travel conditions/access was mentioned as a problem by more than a third of mothers in a six-state survey in Nigeria, and by 43% in Siaya, Kenya, and 30% in Liberia. Poor health staff motivation and performance/competence were also frequently cited as discouraging children's vaccination. Health staff reportedly treated mothers in an unfriendly, disrespectful, or even abusive manner, which discouraged mothers from returning for vaccination. This factor was not prominent in all settings, but was commonly reported in countries such as Ethiopia, Zimbabwe, Niger, Kenya, Bangladesh, West Africa, Uganda, Benin, Nigeria, and Syria. The review also found that lack of resources/logistics was a significant factor in under-vaccination. Insufficient funding and stock outs affected the reliability of services, missed opportunities to immunize, and the cold chain. False contraindications were also mentioned as a factor, where healthcare providers incorrectly identified children as being at risk for adverse reactions to vaccines. The review highlights the importance of providing quality services that are accessible, convenient, reliable, friendly, affordable, and acceptable. Every immunization program should strive to provide such services and solicit feedback from families and community leaders. Monitoring missed and under-vaccinated children and assessing and addressing the causes is also essential.