Julie Cullen, BSc (Hons), MSc, SRN, SCM, CPT
Nurse Consultant: General Practice Nursing/Access to Primary Care, Portsmouth City Teaching Primary Care Trust; and Executive Nurse at the Trust
Most parents accept a health professional’s advice to have their children vaccinated according to the recognised routine schedule (see Policy box below), but there are those who make a conscious decision not to do so.
One of the roles of a practice nurse is to promote the benefits of childhood immunisation and to carry out vaccinations (Atkin et al, 1993). The vaccines used in this country to immunise children are among the safest available, provided their contraindications are observed ((Kassianos, 2001). To deny a child immunisation may be to deny him or her good health.
The success of vaccinations has reduced many of the threats associated with childhood diseases, but if immunisation uptakes drop, childhood diseases could return in epidemic levels and be a threat to the nation’s children (DH, 1996; Mayon-White and Moreton, 1997).
When I began the study reported here, there were 446 children aged two months to four years in my practice, 41 of whom had not received all the scheduled vaccinations at the recommended age, and 10 who had not received any vaccinations at all. These figures encouraged me to investigate the reasons for this lack of uptake. Focusing on parents who had made a conscious decision not to include their children in the vaccination schedule, the exercise aimed to explore why some parents choose not to have their children vaccinated in the absence of medical contraindications.
A qualitative approach, guided by phenomenological methodology (see box, right), was used to study the experience of five parents from different families who had chosen not to have their children vaccinated to produce immunity against childhood diseases. Data were collected using tape-recorded, semi-structured interviews and analysed according to Hycner’s (1985) guidelines (Table 1).
A computer search of the children who had not received any vaccinations by the age of four years provided a cohort of 10 families. The children’s medical records were checked to confirm that they did not have any medical contraindications against vaccination. With permission from the children’s GPs, the parents were contacted by telephone and given an outline of the research and then asked if they would be willing to participate.
It was made clear to them at this point that the intention was not to persuade them to change their decision regarding their children’s vaccinations but, rather, to understand the feelings and experiences that were behind making that decision.
The first two families contacted explained that the children were stepchildren and had previously been vaccinated in other health authorities. This was confirmed and the records were amended. From the remaining eight contacts, four volunteered to attend for vaccination. The other four parents agreed to take part in the research. The fifth participant was from a family that joined the practice list during the time of data collection. The willing participants were given the information required to fulfil the criteria of informed consent.
Three participants were interviewed at home and two attended the surgery. All those interviewed were mothers, and all were supported by their partner in their decision not to have their child vaccinated.
A semi-structured interview in phenomenological methodology demands that open-ended questions are asked (Couchman and Dawson, 1990). The following are some examples of the open-ended questions:
- How did you feel when it was recommended to you that your child be vaccinated?
- What are your feelings now about your child receiving vaccinations?
- What do you feel about your decision not to have your child vaccinated?
It was anticipated that each interview would last about 10 minutes, based on a normal consultation time, but, in fact, each interview lasted about 20 minutes.
The advantage of tape-recording the interviews was that all the conversations could be captured in full (Rose, 1994). To capture the body language, field notes were taken during the interviews.
The interviews were transcribed within a few days of the interview so that the expressions of the participants could be remembered. Repeatedly playing each tape provided an ideal opportunity to listen to each interview for a sense of the whole. Every word was rigorously studied to divide the transcriptions into units of general meaning, keeping the literal words of each parent throughout.
Colleagues were trained to verify the choice of units relevant to the research question and then to oversee the elimination of non-relevant comments. Between 53 and 98 units of relevant meaning were elicited from each interview. Although personal interpretation was avoided as much as possible, it is recognised that other researchers may have chosen different units to eliminate.
The units were then studied to determine which ones naturally clustered together. A cluster is comprised of several units of relevant meaning that have a common theme (Hycner, 1985). Each interview provided 12 to 20 natural clusters. Overall, 25 natural clusters were developed.
Five themes were determined that expressed the essence of the clusters. The participants were contacted again and asked to verify the findings of the themes. At the second meeting, each participant was shown the workings behind each theme, and the interpretations of the data were explained.
Following these discussions, three of the parents volunteered to attend with their children for vaccination. All the participants agreed to the grouping of the clusters, but gave differing opinions on the naming of the themes. By taking these opinions into account, the themes could be determined. The five themes were apparent in all the interviews and therefore were considered to be general themes rather than unique ones.
To fulfil stages 14 and 15 of Hycner’s guidelines, the contextualisation of the themes is shown in (Table 2).
Discussion of the findings
Twenty-five clusters were developed into five themes (Table 2) that were general to all the interviews.
The experiences relating to each theme were examined separately and in detail, and all were interdependent. The fear of damage and perceived contraindications are a result of conflicting information. Those who did not vaccinate their children were anxious about the risks associated with the safety of the vaccine and, because of a lack of understanding about the diseases from which the vaccine was offering protection, underestimated the potential benefits of vaccination.
The false sense of security from knowing others are vaccinated and that therefore it is not worth taking the risk of vaccinating your own child could be said to be a selfish action if the consequences of all parents refusing vaccination are faced. However, my study showed that parents had an inaccurate perception of the risks versus benefit ratio owing to a lack of knowledge about the diseases.
Because of the emotional issues involved in discussing the subject of vaccination, even after the parents had made a decision not to vaccinate their child, it was apparent from the study that, although the parents recognised vaccination as a positive action, they could not overcome concerns about the safety of the vaccine.
Limitations of the research
Researcher bias was minimised in the study taking the following steps:
- Following rigorous guidelines
- Using bracketing
- Having the data analysis verified by independent judges
- Postponing the literature search until after the data analysis.
However, I already had a considerable amount of knowledge about childhood diseases and vaccines and had nursed children dying from pertussis.
For children who have already missed their scheduled vaccinations, it was shown that the health professional needs to make contact with the parent. Most are willing to act upon new information. The parents in this study responded well to telephone contact, and this means of communication continues at the practice. If there is no contact within three months, the health visitor is informed and a home visit will be made.
Educating parents to appreciate the importance of the vaccination schedule and the consequences of not having their child vaccinated is paramount. In my practice, parents are encouraged to discuss any concerns they may have, and are given verbal and written information as appropriate.
Parents require information to balance the risks of having a childhood disease against the risks of having the vaccine. Health professionals need to be up to date so that they can give consistent and accurate information.
There may be a variety of reasons why children miss their scheduled vaccinations, but a health professional making contact with the parents can help ensure that informed decisions are made.
Current recommended childhood immunisations
- 2, 3 and 4 months: diphtheria, tetanus, acellular pertussis, Hib, polio - one injection; meningococcal C conjugate in a second injection
- 12-15 months: measles, mumps and rubella (MMR) in one injection
- 3 years 4 months-5 years: booster of diphtheria, tetanus, acellular pertussis, polio in one injection; MMR booster in a second injection
- 10-14 years: BCG to protect against tuberculosis
- 13 years-18 years: booster of tetanus, diphtheria and polio (one injection). Phenomenology as a research method
Phenomenology is a qualitative, inductive, descriptive methodology, seeking the transaction between the individual and his/her environment as it is perceived (Omery, 1983). It attempts to uncover the meaning of human experience, describing it as it is lived, with layers of meaning interpreted from explanation and knowledge (Munhall and Oiler, 1986). There are many methods for analysing phenomenological data (Omery, 1983). Hycner’s guidelines (1985) for the phenomenological analysis of interview data were chosen for this study because they offer 15 clear, step-by-step procedures for data analysis (see Table 1).
Author contact details
Julie Cullen, Portsmouth City TPCT, Trust Central Office, St James’ Hospital, Locksway Road, Portsmouth, Hampshire PO4 8LD. Email: firstname.lastname@example.org
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