Journal of the New Zealand Medical Association, 12-October-2007, Vol 120 No 1263
Meningococcal B: tell me everything you know and everything you don’t know. New Zealanders’ decision-making regarding an immunisation programme
Paul B Watson, Judy Yarwood, Kim Chenery
The success of the Ministry of Health’s recent meningococcal B (MeNZB™) immunisation programme was dependent upon parents choosing to immunise their children. And a high level of vaccine uptake was a priority in preventing disease.1
Prior to the MeNZB campaign, literature indicated New Zealand parents preferred to visit their general practitioner for vaccinations.2 Moreover, a significant number of parents had low confidence in vaccination and did not trust received government vaccination information.3,4
Several studies have identified variables that seem to influence vaccination uptake including the use of combination vaccines and access to information.5,6 However, these studies insufficiently explain individual decision-making processes.
Relatively little qualitative research into parents’ decision-making about childhood vaccination has been carried out.7 This study aimed to explore how parents made decisions in relation to their child(ren)’s participation in the MeNZB immunisation programme and the factors that influenced their decisions.
For this qualitative descriptive study, recruitment was through advertisements in two free community newspapers delivered to Christchurch households. We sought families who consented, and who did not consent to have their child(ren) receive the meningococcal B immunisation.
Inclusion criteria required participants to be:
Ethical approval was granted by the Upper South B Regional Ethics Committee and Christchurch Polytechnic Institute of Technology Ethics Committee. Data collection took place between November and December 2005. Semi structured interviews focused on parent’s descriptions of their decision-making process. Additional questions prompted for details about sources and quality of information and other factors that underpinned decision-making.
All interviews, conducted at a location and time convenient to participants, were audiotaped and lasted between 45 to 60 minutes. Sociodemographic data including parental age and gender, ethnicity, education levels, income, family size, and their child(ren)’s previous immunisation history were also collected.
Transcripts of each audiotaped interview were initially coded line by line by two of the three authors. Codes focussed on actions and events in the parents’ narratives. All three authors then constantly examined the emergent codes, grouped these into thematic categories and compared them across the two groups. Similarities and differences in the decision-making processes were then evaluated.
Interviews were conducted with 21 parents, 10 who had consented to immunisation, 10 who had not, and 1 who had decided to immunise only 1 of their 2 children. Demographic data are presented in Table 1. The majority (18) of interviewees were mothers, 2 were both parents, and 1 was a father. Both groups represented a range of ethnicities and socioeconomic situations.
Of the parents who consented to the MeNZB vaccination, 90% had children who were fully immunised and 10% partially. Conversely, of the parents who did not consent, 40% had not previously immunised their children, and 30% only partially.
Despite reaching different decisions, the majority of parents followed a similar decision-making process consisting of four non-linear phases: a gut reaction, a trigger, reconnaissance, and risk analysis.
A gut reaction—Parents in both groups experienced a gut reaction. They typically described, often in the absence of any specific information about the vaccine, a decision they would probably make:
We pretty much knew we would get it done when we heard about it (Participant 1: immuniser)
Everyone around me was saying ‘yes’ and I was actually feeling like ‘no’ (Participant 19: non-immuniser)
Although two parents subsequently changed their mind, most remained committed to this initial decision. All parents expressed concern about the seriousness of meningococcal disease, however those parents who chose not to vaccinate believed there were other protective measures and perceived their child to be less susceptible:
I have been a LaLeche League leader so to me breast feeding is the ultimate in protecting our children’s immune system (Participant 9: non-immuniser)
Parents who chose not to immunise were also more concerned about vaccine safety and efficacy.
Table 1. Demographic characteristics of the study participants
Note: To ensure anonymity, the demographic characteristics of the one participant who decided to immunise one child and not the other have been withheld.
A trigger—Most parents identified a trigger, either a person, an event, or the media confirming local availability of the vaccine. The trigger for most of those with school-age children was a consent form sent home from school. Triggers varied for parents of pre-school children, some mentioned talking to or receiving notification about vaccine availability from their general practitioner. Several parents referred to the media as a trigger. Information disseminated by the media was approached with scepticism by most parents:
I mean I’m not silly and I know that the media presents what they want. They want a newsworthy story that someone’s going to watch so they are always going to promote the worst or best of something (Participant 16: immuniser)
Several parents were influenced in some way by Baby Charlotte’s story. An emotional response served to change one parent’s mind in favour of vaccination:
I decided not to...I didn’t know much about it and the immunisation has only been around or a wee bit not like the other immunisations that have been around for years, so I actually watched the television of that little girl who lost her arms and legs and you know I thought ‘Yeah I might get them done’ so I did (Participant 6: immuniser)
Others were more cynical and believed intense media coverage of Charlotte’s story and her father’s presence at public meetings to be a deliberate Ministry strategy designed to influence vaccine uptake:
He [Peri Bisman] showed a lot of photos, a slide-show type thing...by the time he’d got to the end, it was like he was trying to brainwash you into having it done, not so much because it happened to his child but you really got the feeling that he was being paid by the Health Department to be there (Participant 10: dual decision)
Whatever the trigger, these were a cue to action and a reconnaissance phase.
Reconnaissance—Characterised by a ‘hunt’ for information about vaccine safety and efficacy, reconnaissance was undertaken in a variety of ways including reading medical and scientific articles, surfing the Internet, and both watching and reading populist media.
For many parents reconnaissance encompassed wanting to ‘hear’ a family member, friend or trusted health professional thoughts about vaccination. This information was influential for some parents in that it clarified information from other sources, confirmed their own thoughts, or gave them the confidence to act:
The nurse at my kids’ doctors, she’s just brilliant. She’s got little ones of her own so she’s really up with it and I talked to her about her son getting immunised so that kind of helped out a bit too...it was more the side-effects, I thought yeah ‘I can handle that’... just to know from someone that has had their kids done to actually know what happens (Participant 6: immuniser)
Parents wanted accurate, balanced, and referenced information from Ministry of Health officials and health professionals, however, most reported dissatisfaction and mistrust with ‘official’ information received:
If they were able to say ‘we haven’t done it’, just come out and say ‘we haven’t done it’, be honest about it, but they couldn’t be and I think that is why they had to make such a media deal of it because they didn’t have the answers (Participant 3: non-immuniser)
Parents who consented to vaccinate, and those who declined, frequently described the Ministry of Health media publicity as ‘scare mongering’, ‘controlling people through fear’, ‘fear driven’, ‘not balanced’, and ‘one-sided’. Even those with a more positive view made comments such as ‘presenting the Government’s received view’ and ‘needing in some way to twist it to force people to immmunise’.
Considerable dissatisfaction was expressed from both groups of parents with school-age children. Parents were concerned about the graphic nature of information given directly to children at school, in most cases without consent. This heightened fear amongst some children and parents felt it undermined their choice:
They came home from school having seen the promo, they actually sent a video around the schools, they showed it to children as part of the health programme unbeknown to parents and they all came home within 2 days of each other saying, “Oh I’ve got to have this injection or we’re going to get this horrible disease. So really faced with the fear of the children, I felt like I didn’t have a choice (Participant 16: immuniser)
Concern was also voiced about the incentives used to encourage children to return consent forms within 3 days, and again parents felt under undue pressure to make a quick decision. Overall parental sentiment and need for information was summed up in the words of one parent who said:
...just tell me everything you know and everything you don’t know (Participant 21: immuniser)
Risk analysis—Balancing the risk of contracting meningococcal B versus the risks and benefits of the vaccine was interwoven with reconnaissance. Importantly for both groups this process was taken seriously, was focused on individual children and was influenced by multiple factors relevant to each child, family experiences, and their context.
The perceived seriousness of meningococcal B and the perceived risk of contracting the disease were significant considerations for both sets of parents. Those who consented tended to have a strong perception of the seriousness of the disease particularly in relation to the diagnostic difficulties, the sudden onset and the fatal or disfiguring consequences. In consenting parents, the perceived seriousness of the disease was more dominant than the perceived risk of contracting the disease. Vaccine efficacy and safety issues seemed less of a concern.
In contrast, parents who declined immunisation may or may not acknowledge the seriousness of the disease but tended to perceive a lower risk of contracting the disease. Most did so by either denying the existence of an epidemic or stating that it was already in decline. Other reasons given included geographic location, ethnicity, socioeconomic status, health status, nutrition e.g. breastfeeding, and prevention measures such as not sharing drink bottles. For these parents, vaccine efficacy and safety issues were a dominant theme. They commonly referred to the lack of research, uncertainty about the number of vaccinations required to have an effect, and uncertainty about the duration of the coverage and the percentage of people protected by the vaccine.
Vaccine safety issues related to both short-term and long-term side-effects and the fact the vaccine only covered one strain of meningitis. However, perceptions were not always fixed, even after a decision had been made:
She had no adverse effects to any of the jabs and that was another factor that if she had had a bad reaction to any of them I would have pulled her out of the programme (Participant 12: immuniser)
Having made a decision, the majority of parents continued to reflect on it. Most voiced a degree of uncertainty about their decision:
100% [confident] no but I’d say 90% we’ve done what we can to protect our children...hopefully there will be no side effects, no long term problems out of it (Participant 15: immuniser)
It’s a nerve-wracking decision all round, just making the decision about vaccination and I did at times feel like you’re damned if you do and damned if you don’t with this (Participant 11: non-immuniser)
Our findings are similar to results from other qualitative studies suggesting parental beliefs about immunisation influence decisions.8–10 Of the parents in our sample who previously believed in fully immunising their children, only 30% declined the MeNZB vaccine. Nevertheless our study has shown the decision to (or not to) vaccinate was far from routine. These results concur with a 1998 Australian study that found perceptions of susceptibility to disease and vaccine safety are dynamic.8
The biggest mass immunisation programme undertaken in New Zealand, MeNZB, confronted unique challenges. To affect the incidence of meningococcal disease in New Zealand, high levels of vaccine uptake were required, because immunisation with serogroup B meningococcal vaccines did not seem to reduce nasopharyngeal colonisation by the organism.1
National telephone research about the MeNZB vaccine conducted prior to roll-out showed that while disease awareness was high, perceptions of personal relevance was considerably lower.11 Not surprisingly Ministry of Health publications and the mass media campaign surrounding the programme sought to address this issue by raising the perception of risk.
Statements in the Ministry fact sheets such as ‘everybody in New Zealand is at high risk of contracting the disease’ and ‘the trials have found that the vaccine was safe’ did little to raise individual perceptions of risk for most parents in this study or satisfy their concerns over vaccine safety and efficacy.
Indeed, recent New Zealand research indicates that information from official sources openly promoting immunisation is viewed by many parents as biased.12 And in this study while parents who chose not to immunise were more likely to express a distrust of official information, those that did immunise were not prepared to take it at face value either.
Mass media campaigns to promote vaccination have been shown to be effective and the legitimacy of using stories and images of children affected by diseases to convey the seriousness of vaccine preventable diseases has been argued.13,14 Media coverage of Charlotte’s story heightened perceptions of risk and arguably was intended to illustrate the irrationality of choosing not to vaccinate. For a few parents in this study this strategy appeared to have the desired effect. However, our data also shows for other parents it had the opposite effect and may have undermined public trust in the Ministry of Health regardless of whether parents agreed with the immunisation or not.
Public trust is essential for immunisation programmes and should be protected.15 Any undermining of trust could have negative consequences for future programmes.
School-based immunisation programmes have been shown to be effective.16,17 Our data indicates both sets of parents had concerns about the graphic nature of information given directly to children, the short-time frame for return of consent forms, and the use of child focussed incentives.
Interestingly, prior to the meningococcal B programme the use of incentives in schools was reported as improving the rate of returned consent forms.2 However, some parents in this study felt child focussed incentives, used in some schools to achieve a quick return of consent forms compromised their ability to make an informed decision.
The Ministry of Health, in the context of a 14-year epidemic of group B meningococcal disease, initiated the MeNZB immunisation program. For parents in our study intricacies within the family context were just as (if not more) important in reaching a decision. Therefore parents’ perceived balance of risk for their individual child may not coincide with the health authorities balance of risk at the population level.18
The parents we interviewed all followed a similar decision-making process, were influenced by similar factors and sought information about the MeNZB vaccine from a variety of sources.
Limitations of this study were its small sample size and single geographic location. Despite these limitations, a qualitative method allowed us to gather comprehensive information from parents.
Despite different outcomes, most parents experienced comparable influences, and followed similar decision-making processes, which have been identified in previous studies regarding parental decision-making related to childhood immunisations.
Risk analysis (one of four interwoven decision-making phases) demonstrated that whatever decision is made, parents do not undertake the process lightly. Indeed, decisions regarding their children’s wellbeing were made with considerable thought, questioning, and discussion. The use of fear, however, to encourage immunisation in the context of this campaign was not received favourably and requires debate.
Furthermore, parents’ generally negative view of communication strategies used at this time also has implications and deserves consideration for future mass immunisation programmes.
Competing interests: None.
Author information: Paul B Watson, Senior Lecturer, School of Nursing, Christchurch Polytechnic Institute of Technology (CPIT), Christchurch; Judy Yarwood, Principal Lecturer, School of Nursing, CPIT, Christchurch; Kim Chenery, Clinical Nurse Educator, Child Health Cluster, Christchurch Hospital, Canterbury District Health Board, Christchurch
Acknowledgements: Funding for the study was provided by the Christchurch Polytechnic Institute of Technology, Academic Research Committee. We also thank the parents who generously gave their time to tell us their experience of making decisions for their children about the MeNZB vaccine, as well as Lisa Phillips who transcribed the interviews.
Correspondence: Paul Watson, Senior Lecturer, School of Nursing, Christchurch Polytechnic Institute of Technology, PO Box 540, Christchurch; Fax: (03) 940 8019; email: email@example.com
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