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A qualitative analysis of parental decision making for childhood immunisation

A qualitative analysis of parental decision making for childhood immunisation Australian Institute for Primary Care, Faculty of Health Sciences, La Trobe University, Victoria Abstract Objective: Achieving high rates o f childhood immunisation is an important public health aim. Currently, however, immunisation uptake in Australia is disappointing. This qualitative study investigated the factors that influence parental decision making for childhood immunisation, and whether parents’ experiences were better conceptualised in terms o static subjective expected utility f models or in terms o a more dynamic f process. Merhod: Semi-structuredin-depth interviews were conducted with 20 predominantly middle-class mothers - 17 imrnunisers and three non-immunisers, in Melbourne, Victoria, in 1997. The data were then examined using thematic analysis. Results: The results suggested that for these participants the decision regarding childhood immunisation was better conceptualised as a dynamic process. The decision required initial consideration, implementation then maintenance. Conclusion: If a better understanding o f immunisation decision making i to be s achieved, future studies must look beyond static frameworks. Implication: Clearer insight into the dynamic nature o immunisation decision f making should assist in the identification of more effective methods of promoting childhood immunisation to groups at risk of non-compliance. (Ausf N Z J Public Health 1999;23:543-5) long with environmental public health measures, childhood immunisation has been one of the most successful and cost-efficient global public health pr0grarns.l Although the majority of Australian parents reportedly support immunisation, incomplete primary immunisation persists. An estimated 52.1% of Australian children six years and under have received their age-appropriate vaccinations (33% if the relatively recent haemophilus influenzae type b (hib) vaccination is included). This is well below the Federal Government’s target of 95% by the year 2000 and the National Health and Medical Research Council’s recommendation of at least 90% coverage of two year olds and near 100%coverage for schoolaged The models currently dominant in explaining preventive health behaviour adopt a cost-benefit decision-making perspective. These value expectancy models propose that knowledge and experience with particular settings shape attitudes and beliefs, which in turn predict the likelihood of particular behaviours. The Health Belief Model (HBM) is one of the most widely researched of these modek6 In general, however, only weak to moderate correlations have been found for the HBM components, rarely accounting for more than 40% of variance.’-’ Explanations for the failure of this model to adequately explain the variation in health behaviours have been advanced, including: the use of invalid questionnaires; limited sample sizes; and failure to properly operationalise theoretical constructs (e.g. Champion).l0 It is possible, however, that these models fail because they do not adequately address the importance of environmental influences in health behaviour and because they adopt a static analysis of the process of behavioural change. An alternative approach to understanding the parental experience of immunisation is offered by the Transtheoretical Model. This dynamic model suggests that health-related decision making and action often progress through a process of pre-contemplation, contemplation,preparation, action and maintenance. This study examined qualitatively the decision making which parents report undertaking in relation to the immunisation of their children, with a view to better understanding how this phenomenon should be conceptualised in the future. ‘ Method A snowball sample of 20 mothers, aged 24 to 41 years, with at least one pre-school age child was recruited. Participants were drawn from an informal network ofpredominantly middle-class friends and acquaintances. This technique, which sampled for understanding, was chosen because the study aimed to contribute to the development of theory rather than testing any existing theory in the field. Seventeen of the participants were fully up to date with their child’s immunisations and three had never immunised their child. Six participants had one child, nine had two children, one had three and another had four children. Twelve participants were educated to tertiary level, six to full secondary level, and two to part secondary level. The family Correspondence to: Assoc. Prof. Hal Swerissen, Australian Institute for Primary Care, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria 3083. Fax: (03)9479 5977; e-mail: h.swerissen@latrobe.edu.au Submitted: September 1998 Revision requested: January 1999 Accepted: July 1999 1999 v o ~23 NO. 5 . AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Marshall and Swerissen Brief Report income of 11 participants was less than $50,000 and for nine participants it was more than $50,000. Semi-structured interviews of approximately one hour’s duration were conducted in participants’ homes or other convenient, private settings; and demographic information was collected. Participants were informed that the study aimed to investigate what factors parents identify as influencing their decision whether or not to have their children immunised. Prior to the commencement of interviews, participants were given a general outline of the interview structure. Participants who indicated they had fully immunised their child were asked first to relate their child’s immunisation history, including the carer’s decision making, perceptions and reactions to taking the child to be vaccinated. Participants who had not immunised their child were asked to relate the issues considered in this decision. Both groups were asked more specific questions to determine the extent to which their experiences were explained adequately by static and dynamic models of health decision making. For participants with more than one pre-school child, the youngest child’s immunisation story was the focus of questioning, although participants were encouraged to elaborate on the impact of any older children’s immunisation experiences. All participants voluntarily consented to participate and understood that they were at liberty to withdraw from the study at any time. All agreed to have their interviews audio-taped. Approval for this study was given by the Human Ethics Committee, Faculty of Science and Technology, La Trobe University. After the audio-taped interviews were transcribed they were segmented into idea units, then categories were established which represented the data, as described by Berg, Minichiello et al. and Walker.12-’4 These units were coded by the rater into thematic categories. An independent rater coded a randomly selected sub-set of the transcripts to verify the adequacy of the thematic categories chosen. Details of these thematic categories are available from the authors. Results and discussion For the participants in this study, the decision whether or not to immunise their child was not a static, point-in-time activity, but a dynamic process which involved three steps: considering, implementing and maintaining. Each iteration of the decision-making process (2,4,6,12and 18 months) involved revisiting these steps. In some instances, a reassessment of the original decision, a reconfirmation of it or a plan to alter the subsequent performance was required, which impeded progression through the steps. Where no alteration to the original steps was needed, movement through the steps was swift. Although there was considerable variability in the carers’ decision making, the results suggest that the HBM provides a partial explanation of immunisation behaviour. Both immunisers and nonimmunisers weighed up the barriers and benefits of immunisation (e.g. the safety of the vaccines, inflicting pain on their child, long- and short-term side effects versus protecting their child from the diseases and community benefit). Some sought formal and informal information and the process was complex, burdensome and accompanied by high levels of anguish -“it’s something you’re doing for [your children], not knowing what the outcome could be”. For others, weighing up was cursory and associated with little or no anxiety. The immunisation experience also varied at many points in the process and across time. For some, far greater energy was expended at the decision point; others, however, experienced much more difficulty in maintaining performance. Participants brought not only all their prior immunisation experiences (whether with the current child or older siblings) but also other life experiences to bear on the next decision whether or not to immunise. For some, there was a constant reassigning of priorities through the various iterations of the immunisation process. Both the decision and action were embedded within the parents’ ever-changing lives. Immunisation either was integrated with competing life demands or at a given point in time became the focal life demand. The latter was particularly so for first-time mothers during those anxious periods when the initial decision had to be made or when the first few vaccinations were undertaken. As their child grew, some mothers became more confident in their parental role and perceived their child as less vulnerable, and as other life activities intervened their perception of immunisation and its importance altered. “It seemed to be that you and your child were involved in more things” and so the immunisation appointment slipped in priority. Although many of the participants had ultimately immunised their children, they implicated factors such as time constraints and their increasing confidence in parenthood as bearing on their experience, leading some to procrastinate or forget. For others, a contraindication, such as a cold, delayed the immunisation until the child’s health had improved. This was particularly so when the child was young or the mother was inexperienced. Having implementedtheir decision, participants either reviewed, consolidated or defended their position. For immunisers, consolidating their position involved either remembering to complete the schedule or keeping the immunisation issue apriority in their lives until the 18-month booster was completed. Cues such as reminders from the maternal and child health nurse helped to maintain this commitment. Non-irnmunisers reported having to constantly consolidate their position by reaffirming their alternative beliefs in the face of varying degrees of opposition. It seems that non-immunisers are more likely to have to defend their position or avoid confrontation regarding their choice, particularly during periods of higher disease prevalence. The findings of this research suggest that successful interventions will need to provide ongoing supportive environments to parents to encourage immunisation compliance. Such support will need to be provided at each point in the immunisation process. It seems likely that prompting, as well as reassurance pertinent to the specific problems parents are encountering at the time, will have maximum effect in encouraging parents’ ongoing commitment to immunisation. Such encouragement would best come from either the carer’s maternal and child health nurse or GP 1999 VOL. 23 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Brief Report Parental decision making for childhood immunisation This study was primarily concerned with hypothesis building. It was limited to an investigation of essentially middle-class immunisers. The personal and physical resources available to the participants of this study may not reflect those available to other groups. Future studies need to target the full spectrum of primary carers (including gender, SES and educational background) and the three immunising groups (full, partial and non-immunisers) in order to ascertain whether the framework suggested in the present study can be applied to all immunising groups. It is hoped that by understanding more fully the dynamic nature of immunisation decision making, more effective ways of promoting childhood immunisation to groups at risk of non-compliance can be identified. 3. Bazeley P Kemp L. Childhood immunisarion - the role o parents and serv, f ice providers. a review of the litemture. Canberra: AGPS, 1994. 4. Cauchi S. Low immunisation rate leaves children exposed TheAge 1997 Jan http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

A qualitative analysis of parental decision making for childhood immunisation

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Publisher
Wiley
Copyright
Copyright © 1999 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1999.tb01316.x
Publisher site
See Article on Publisher Site

Abstract

Australian Institute for Primary Care, Faculty of Health Sciences, La Trobe University, Victoria Abstract Objective: Achieving high rates o f childhood immunisation is an important public health aim. Currently, however, immunisation uptake in Australia is disappointing. This qualitative study investigated the factors that influence parental decision making for childhood immunisation, and whether parents’ experiences were better conceptualised in terms o static subjective expected utility f models or in terms o a more dynamic f process. Merhod: Semi-structuredin-depth interviews were conducted with 20 predominantly middle-class mothers - 17 imrnunisers and three non-immunisers, in Melbourne, Victoria, in 1997. The data were then examined using thematic analysis. Results: The results suggested that for these participants the decision regarding childhood immunisation was better conceptualised as a dynamic process. The decision required initial consideration, implementation then maintenance. Conclusion: If a better understanding o f immunisation decision making i to be s achieved, future studies must look beyond static frameworks. Implication: Clearer insight into the dynamic nature o immunisation decision f making should assist in the identification of more effective methods of promoting childhood immunisation to groups at risk of non-compliance. (Ausf N Z J Public Health 1999;23:543-5) long with environmental public health measures, childhood immunisation has been one of the most successful and cost-efficient global public health pr0grarns.l Although the majority of Australian parents reportedly support immunisation, incomplete primary immunisation persists. An estimated 52.1% of Australian children six years and under have received their age-appropriate vaccinations (33% if the relatively recent haemophilus influenzae type b (hib) vaccination is included). This is well below the Federal Government’s target of 95% by the year 2000 and the National Health and Medical Research Council’s recommendation of at least 90% coverage of two year olds and near 100%coverage for schoolaged The models currently dominant in explaining preventive health behaviour adopt a cost-benefit decision-making perspective. These value expectancy models propose that knowledge and experience with particular settings shape attitudes and beliefs, which in turn predict the likelihood of particular behaviours. The Health Belief Model (HBM) is one of the most widely researched of these modek6 In general, however, only weak to moderate correlations have been found for the HBM components, rarely accounting for more than 40% of variance.’-’ Explanations for the failure of this model to adequately explain the variation in health behaviours have been advanced, including: the use of invalid questionnaires; limited sample sizes; and failure to properly operationalise theoretical constructs (e.g. Champion).l0 It is possible, however, that these models fail because they do not adequately address the importance of environmental influences in health behaviour and because they adopt a static analysis of the process of behavioural change. An alternative approach to understanding the parental experience of immunisation is offered by the Transtheoretical Model. This dynamic model suggests that health-related decision making and action often progress through a process of pre-contemplation, contemplation,preparation, action and maintenance. This study examined qualitatively the decision making which parents report undertaking in relation to the immunisation of their children, with a view to better understanding how this phenomenon should be conceptualised in the future. ‘ Method A snowball sample of 20 mothers, aged 24 to 41 years, with at least one pre-school age child was recruited. Participants were drawn from an informal network ofpredominantly middle-class friends and acquaintances. This technique, which sampled for understanding, was chosen because the study aimed to contribute to the development of theory rather than testing any existing theory in the field. Seventeen of the participants were fully up to date with their child’s immunisations and three had never immunised their child. Six participants had one child, nine had two children, one had three and another had four children. Twelve participants were educated to tertiary level, six to full secondary level, and two to part secondary level. The family Correspondence to: Assoc. Prof. Hal Swerissen, Australian Institute for Primary Care, Faculty of Health Sciences, La Trobe University, Bundoora, Victoria 3083. Fax: (03)9479 5977; e-mail: h.swerissen@latrobe.edu.au Submitted: September 1998 Revision requested: January 1999 Accepted: July 1999 1999 v o ~23 NO. 5 . AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Marshall and Swerissen Brief Report income of 11 participants was less than $50,000 and for nine participants it was more than $50,000. Semi-structured interviews of approximately one hour’s duration were conducted in participants’ homes or other convenient, private settings; and demographic information was collected. Participants were informed that the study aimed to investigate what factors parents identify as influencing their decision whether or not to have their children immunised. Prior to the commencement of interviews, participants were given a general outline of the interview structure. Participants who indicated they had fully immunised their child were asked first to relate their child’s immunisation history, including the carer’s decision making, perceptions and reactions to taking the child to be vaccinated. Participants who had not immunised their child were asked to relate the issues considered in this decision. Both groups were asked more specific questions to determine the extent to which their experiences were explained adequately by static and dynamic models of health decision making. For participants with more than one pre-school child, the youngest child’s immunisation story was the focus of questioning, although participants were encouraged to elaborate on the impact of any older children’s immunisation experiences. All participants voluntarily consented to participate and understood that they were at liberty to withdraw from the study at any time. All agreed to have their interviews audio-taped. Approval for this study was given by the Human Ethics Committee, Faculty of Science and Technology, La Trobe University. After the audio-taped interviews were transcribed they were segmented into idea units, then categories were established which represented the data, as described by Berg, Minichiello et al. and Walker.12-’4 These units were coded by the rater into thematic categories. An independent rater coded a randomly selected sub-set of the transcripts to verify the adequacy of the thematic categories chosen. Details of these thematic categories are available from the authors. Results and discussion For the participants in this study, the decision whether or not to immunise their child was not a static, point-in-time activity, but a dynamic process which involved three steps: considering, implementing and maintaining. Each iteration of the decision-making process (2,4,6,12and 18 months) involved revisiting these steps. In some instances, a reassessment of the original decision, a reconfirmation of it or a plan to alter the subsequent performance was required, which impeded progression through the steps. Where no alteration to the original steps was needed, movement through the steps was swift. Although there was considerable variability in the carers’ decision making, the results suggest that the HBM provides a partial explanation of immunisation behaviour. Both immunisers and nonimmunisers weighed up the barriers and benefits of immunisation (e.g. the safety of the vaccines, inflicting pain on their child, long- and short-term side effects versus protecting their child from the diseases and community benefit). Some sought formal and informal information and the process was complex, burdensome and accompanied by high levels of anguish -“it’s something you’re doing for [your children], not knowing what the outcome could be”. For others, weighing up was cursory and associated with little or no anxiety. The immunisation experience also varied at many points in the process and across time. For some, far greater energy was expended at the decision point; others, however, experienced much more difficulty in maintaining performance. Participants brought not only all their prior immunisation experiences (whether with the current child or older siblings) but also other life experiences to bear on the next decision whether or not to immunise. For some, there was a constant reassigning of priorities through the various iterations of the immunisation process. Both the decision and action were embedded within the parents’ ever-changing lives. Immunisation either was integrated with competing life demands or at a given point in time became the focal life demand. The latter was particularly so for first-time mothers during those anxious periods when the initial decision had to be made or when the first few vaccinations were undertaken. As their child grew, some mothers became more confident in their parental role and perceived their child as less vulnerable, and as other life activities intervened their perception of immunisation and its importance altered. “It seemed to be that you and your child were involved in more things” and so the immunisation appointment slipped in priority. Although many of the participants had ultimately immunised their children, they implicated factors such as time constraints and their increasing confidence in parenthood as bearing on their experience, leading some to procrastinate or forget. For others, a contraindication, such as a cold, delayed the immunisation until the child’s health had improved. This was particularly so when the child was young or the mother was inexperienced. Having implementedtheir decision, participants either reviewed, consolidated or defended their position. For immunisers, consolidating their position involved either remembering to complete the schedule or keeping the immunisation issue apriority in their lives until the 18-month booster was completed. Cues such as reminders from the maternal and child health nurse helped to maintain this commitment. Non-irnmunisers reported having to constantly consolidate their position by reaffirming their alternative beliefs in the face of varying degrees of opposition. It seems that non-immunisers are more likely to have to defend their position or avoid confrontation regarding their choice, particularly during periods of higher disease prevalence. The findings of this research suggest that successful interventions will need to provide ongoing supportive environments to parents to encourage immunisation compliance. Such support will need to be provided at each point in the immunisation process. It seems likely that prompting, as well as reassurance pertinent to the specific problems parents are encountering at the time, will have maximum effect in encouraging parents’ ongoing commitment to immunisation. Such encouragement would best come from either the carer’s maternal and child health nurse or GP 1999 VOL. 23 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Brief Report Parental decision making for childhood immunisation This study was primarily concerned with hypothesis building. It was limited to an investigation of essentially middle-class immunisers. The personal and physical resources available to the participants of this study may not reflect those available to other groups. Future studies need to target the full spectrum of primary carers (including gender, SES and educational background) and the three immunising groups (full, partial and non-immunisers) in order to ascertain whether the framework suggested in the present study can be applied to all immunising groups. It is hoped that by understanding more fully the dynamic nature of immunisation decision making, more effective ways of promoting childhood immunisation to groups at risk of non-compliance can be identified. 3. Bazeley P Kemp L. Childhood immunisarion - the role o parents and serv, f ice providers. a review of the litemture. Canberra: AGPS, 1994. 4. Cauchi S. Low immunisation rate leaves children exposed TheAge 1997 Jan

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Oct 1, 1999

There are no references for this article.