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Evidence Based Nursing Research


Discuss about the Evidence Based Nursing Research.



In this article, Glanz et al., (2010) describe a research study, which intends to quantify the attributable risks of varicella infection in children whose parents refuse the varicella immunizations. The author has used matched case-control study to establish the link between parental refusal of vaccination and likelihood of varicella infection in children. The research was conducted by examining the data of the health plan “Kaiser Permanente Colorado” (KPCO) for a 10-year period on the status of vaccination and disease of the enrolled children.

This cohort study included 133 patients with diagnosed case of varicella and data obtained from these patients was matched to a control group of 493 patients. The control group participated in the study has no history of varicella infection. The study has considered only potential cases of varicella as obtained from KPCO database. The inclusive criteria of the study population include-

  • Age- 12 months - 8 years
  • Continuous enrollment of children in KPCO between 1998-2008 and
  • Children should have been diagnosed with varicella at least of 6 months for being eligible for the study

The exclusion criteria for the study population include

  • Cases that were diagnosed with varicella infection before 12 months of age, as they are not immunized
  • Children who were diagnosed with Varicella before 14 days of the study were excluded from the study as they need more time to develop full immune response
  • Absence of justified medical records for lack of vaccination

For subanalysis, conditional logistic regression was used to calculate the total percentage of the attributable risks at both individual levels and in children refused to take a vaccine. The data was matched based on sex, age and the length of study in the hospital. The data collected were tested for statistical significance (95% confidence interval). The results of the study showed that the varicella infection was strongly associated with vaccine refusal, "odds ratio, 8.6; 95% confidence interval, 2.2-33.3; P=.004”. 99.4% of the total vaccine refusers had attributable risks and were statistically significant.

The findings of this research confirmed that Parental refusal of varicella vaccine subjected their children to the high risk of varicella infection when compared to the vaccinated counterparts. The study has excluded potential biases, which may commonly occur due to misclassification of the outcome and the exposure cases.  A detailed medical record was performed to validate both case and the vaccination status.

The results of this cohort study have important clinical implications. Immunizations would prevent hospitalizations and reduce the death rate. Vaccine refusers were highly susceptible to infection (9 folds higher) in comparison to the fully vaccinated children. The result has assessed the disease risk at the individual level. The researcher has followed the code of ethics.

The limitation of the study includes selecting the population from single Colorado-based health care plan. It may limit the generalisability of the findings. Physicians may have high probability to diagnose varicella in unvaccinated children than those vaccinated, leading to biases. The strength of the vaccine refusers was only 10 out of 626 cases and controls. Thus, it may prevent correct statistical evaluation. The cases that did not receive medical attention may lead to underestimation of infection risk in vaccine refusers. This research is high helpful for the health care providers in counseling the patients regarding immunization. The findings of this study will assist parents in decision making in regards to their child’s immunization.

In this article, Lee et al., (2016) has aimed to determine the effectiveness of the immunization mandates in children who have regularly received immunization. The primary objective was to identify if mandates increase the immunization uptakes.

In this qualitative and heterogeneous study design, the researchers performed the review of different competitive studies that assessed the effect of immunization in a population before and after mandates or population with and without mandates. The study used systemic review protocol based on PRISMA statement. The inclusion criteria for the systemic review includes-

  • Comparative studies on immunization uptake in similar population with and without a mandate
  • All type of study designs

The exclusion criteria for the systematic review were studies with limited resources and those, which were not in English.

The search strategy used by the reviewers included a use of different databases such as Embase, PubMed, Ovid-Medline, Cochrane Library and CINAHL. The MESH terms mainly used for database search are vaccinations, obligatory, immunizations, vaccines, mandates, rate of uptake. A literature review was performed using the search terms childcare entry, school entry, requirement, law. All the articles met the inclusion criteria and were limited to the pediatric scope. Two authors conducted the review and summarized the findings with main factors beings country, population range, age, study design, any intervention used, and rate of immunization with and without mandate/ pre and post.

Data was collected from 21 studies including “US (n = 18), France (n= 1) and Canada (n= 2)". 11 of these studies were based on middle school mandates, and two of them showed the increase in immunization uptake with mandates. Higher uptake was observed in a case of long-standing mandates. However, the study design being heterogeneous, statistical analysis was not performed.

The research findings showed that there was increased uptake of immunizations in people who were applicable mandates. The authors concluded that uptake of immunization increases with both short-term and long-term mandates if introduced or strictly enforced. Thus, there is need for increased enforcement of mandates at a middle school or school entry level. This study is of great help for preventing infectious diseases in children by increasing immunization uptake. Number of jurisdictions can enact immunization mandates directed by this research study.

It is the only systematic review related to immunization mandates, which is the strength of the study. The research has strictly followed the code of ethics. The limitations of the study include a use of heterogeneous study design in combining and comparing the findings. There was mixed data available regarding increased uptake of immunization with mandates. The confounding factors such as media coverage of vaccine, change in enforcement practices related to mandates, child vaccination program, mandates on vaccine rates were not controlled. This study is useful in counseling people to uptake immunization for their children. However, the effectiveness of the mandates in the child care centers and other countries other than the US was not determined. Further research can be conducted on younger children not applicable for the mandates to assess the effectiveness of the immunization.

Miller et al., (2008) conducted this research to gain rural parent’s perspective about child immunization. The researcher intended to understand what factors influenced parent’s decision regarding immunization of their children. The research study was conducted to explore the type of information that is needed by the parents and what are the trustworthy source that helps in providing relevant information to the patients. Further, it is necessary to understand as to what type of information provokes mothers to immunize their children completely.

In this descriptive qualitative study design, semi-structured interview method was used to gain relevant information from the participants. The nature of the study was exploratory. The participants were mainly mothers with children of two years and below. The research was conducted in Calgary Health Region.  Parents were recruited for the study through nurses working in various childcare programs. The inclusion criteria involve parents-

  • Who are of legal age
  • Have taken immunization decision in the past one year for their child
  • Eligible for routine immunization in Albeta (previous year)
  • Child should be maximum of two years
  • Living in rural communities within the boundary of Calgary Health Region
  • Who are mothers or fathers with varied family sizes, education levels, and ages

The study excluded the respondents who did not meet the inclusion criteria.

The survey questionnaire was sent to the participants by post that had to be filled and submitted to the investigators via email or post. The interview process included collection of data related to

  • Influence of immunization information on their decision,
  • Type of information and content required making the immunization decision
  • What are the trusted sources of information
  • Suggestions from parents regarding the effective method of conveying information

The data collection and analysis was performed simultaneously carefully coding the emerging themes and concepts. This data was compared with previously established categories. Altogether, 35 respondents were eligible for the interview. The process was stopped after 11 interviews due to saturation and repletion of concepts. Principal investigator performed all the coding of transcripts. Additionally, nurses' (n=16) feedback was also collected in the study to gather other relevant information.

The research findings revealed that the primary role played by the varied information received by parents include one of the following-

  • Helped to make the immunization decision
  • Confirming the decision
  • Difficulty in making decision due to increasing in curiosity

Five mothers took the firm decision regarding child's immunization. In some cases, the decision varied due to confusion related to immunization, while some cases parents were waiting for their child to attain particular age. Some participants reported that information was not accurately conveyed which disturbed them. Parents who have taken immunized decision preferred comprehensive, logical and understandable information. Using technical jargon dissatisfied the participants. The trusted sources for mothers were mainly doctors and nurses. Others suggested making information available on websites, in libraries and prenatal classes and health units. Conclusively, parents are convinced once they are enlightened.

The research study has followed the code of ethics set by “Community Research Ethics Board of Alberta (CREBA), Canada." It maintained the anonymity and confidentiality of the respondents. The limitation of the study includes geographical location, which was restricted to the rural areas. This study is helpful in developing information in the easily understandable format such that a number of rural parents uptake immunization for their children. Health professionals are benefitted from such studies as they devise the best method for conveying the vaccination information to the parents influencing their decisions.

By the review of the above three articles it is evident that infectious diseases are leading causes of childhood mortality and morbidity. Children at the early age are highly susceptible to deadly infections such as influenza, pertussis, and measles and other. These infections in children damaged brain, liver, heart, causes pneumonia and death. Immunization has proved to be a significant intervention in reducing the occurrence of infectious diseases in children. Every child needs vaccination at an early age to protect themselves as well as those around them.

It was found from the research papers of Miller et al., (2008), Lee et al., (2016), and Glanz et al., (2010) that parent’s negative perspective is the major barrier to effective immunization. Lack of awareness related to the effectiveness of immunization in minimizing infectious disease, cause most parents to refuse vaccines for their children. His research confirmed that vaccinations would prevent hospitalizations and reduce the death rate. Vaccine refusers were highly susceptible to infection (9 folds higher) in comparison to the fully vaccinated children. Such studies have led to positive clinical implications. However, a number of parents in the present world is firm in immunization uptake for their children. These research studies are highly beneficial as they provide an evidence base to counsel the people and articulate their thoughts.

The other barrier to vaccination includes lack of sufficient information, particularly in rural areas. It greatly influences the decision making a power of parents. Research by Miller et al., (2008) indicated that creating awareness about immunization helps in increased immunization uptake by parents. However, this study was confined to rural areas which limited the scope of research. The research conducted by Glanz et al., (2010) is also limited to the statistical evaluation could have been more accurate. Health professionals play a fundamental role in helping parents make the decision related to immunization by providing comprehensive and logic based information. Parents mostly trust doctors and nurses for gaining health related information. Therefore, health professionals must maintain correct demeanor and attitude to convince parents and satisfy their curiosity. It is recommended that parents are to be well explained the need of immunization and its potential benefits through written and oral presentations.  Providing relevant and plenty of information through websites and emails will make them firmly decide to uptake immunization for their child. Parents who lacked relevant information remained undecided continued to refuse vaccination. Let’s consider an example of Polio vaccine. There was a time where parents feared polio vaccine as it induced paralysis, however; the fight against it is won. Immunization mandates in the US have significantly increased immunization uptake in children (Lee et al., 2016). However, mixed data obtained in this study and its heterogeneous study design limits the accuracy of the findings.  Similar measures should be adopted worldwide because even in the present world exposures to deadly infections occur. Therefore, innovative strategies and robust awareness programs must be particularly increased in rural communities.

Conclusively, a vaccine is a wonderful invention that is saving lives of millions of children. Children are immunized which helps them develop immunity before their exposure to the disease. Since these are cost effective measures, it should be mandated at school entry and mid school level. More research should be conducted in this field to explore positive and negative aspects of present day immunizations.


Glanz, J. M., McClure, D. L., Magid, D. J., Daley, M. F., France, E. K., & Hambidge, S. J. (2010). Parental refusal of varicella vaccination and the associated risk of varicella infection in children. Archives of pediatrics & adolescent medicine, 164(1), 66-70.

Lee, C & Robinson, J.L. (2016). Systematic review of effect of immunization mandates on uptake of routine childhood immunizations. Journal of Infection, 72(6), 659-666.

Miller, N.K, Verhoef, M & Cardwell, K. (2008). Rural parents’ perspectives about information on childhood immunization. Rural and Remote Health, 8(2), 863.

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