Details of the process and numbers involved in the study are illustrated in . A total of 53 participants were invited to take part in the study; 15 participants were ‘non-responders’ at 4 weeks and so were excluded according to the study design. Of the 38 who responded to the invitation and agreed to participate in the study, 22 were not aware that the influenza vaccination was recommended for their child, and, according to the study design, took no further part. The remaining 16 completed the initial questionnaire but only nine of this number consented to provide further information. Of these, five preferred to respond in writing and two preferred a telephone interview. Two chose not to respond further. No participant expressed a preference for face-to-face interview. The final number of participants in part 2 of the study was therefore seven.
Summary flowchart of protocol with participant numbers in brackets and timescale in italics.
Five main themes evolved from analysis of the data (Box 4
Box 4. Themes
- Uncertainty about indication for vaccination
- Issues of choice
- Challenges with access
- Lack of parental priority
- Issues relating to health beliefs
Uncertainty about indication for vaccination
Some parents described issues that would be recognised by health professionals as contraindications to the vaccine, notably egg allergy. However, despite the fact that all children in this study fell within the group for whom seasonal influenza vaccination is indicated, a much greater proportion of parents expressed doubt, scepticism, or a lack of knowledge about the relevance of the vaccination for their child:
‘[Child's] asthma had seemed to be “dormant” for several years so we didn't think a flu jab was necessary. Also, we thought as her asthma is quite mild she wasn't high risk.’ (Parent [P] 1)
‘I have asked if [child] was able and told only if she was hospitalised at some point with asthma. I feel myself she would not benefit from it as her asthma is mild.’ (P31)
‘Unconvinced that the vaccine will fight the strain of flu that's around.’ (P19)
These comments reveal a need for parent education regarding vaccine indication for their children, and also the need for effective communication about the recommendation for vaccination and risks of non-vaccination between the healthcare provider and parent.
Issues of choice
Issues of choice were strongly represented in the data. While the choice described was usually that of the parent, choice for the doctors involved in the care of the child, and indeed those of the children themselves, were taken into account in parental decisions about vaccination:
‘We chose not to — this was due to our understanding that there are many different flu viruses and that the jab only protects against the “most likely”.’ (P19)
‘Has been diabetic since age seven, is now 16 therefore would have had nine un-necessary injections.’ (P28)
‘After consulting with [child's] doctor about this vaccine in relation to [child's] egg allergy, the doctor in turn consulted a paediatrician at [hospital] (where the child received his first MMR [measles, mumps and rubella] jab last year with no obvious ill effects) who advised against him receiving the vaccine in 2007. Even if the doc [paediatrician] had advised going ahead with the flu vaccine, I don't think I would have, for various reasons!’ (P35)
‘She didn't want the flu jab as she is afraid of needles.’ (P43)
While choice will always play a key role in decisions of parents as to whether to vaccinate their children, there is a key role for healthcare providers in ensuring that the choices that are made are informed ones.
Challenges with access
Analysis of the data revealed several described barriers to accessing vaccination. These included a lack of a personal invitation from the practice, difficulties gaining an appointment, and the challenges of intercurrent illnesses compounding appointment difficulties:
‘He wasn't using his steroid inhaler all the time (mainly during hay fever season) and as he wasn't asked to come we were unsure of his eligibility for the vaccine.’ (P21)
‘I made an appointment for [child] to get her flu jab, the clinic was busy and it was well into November before I could get an appointment for her. By which time she was unwell with chest infections, or if not had temperatures. [Child] did actually get her flu jab last winter but it was actually February 2008 before she was well enough to have it.’ (P33)
At present, responsibility for invitation for vaccination lies with individual GP practices, without regional or national coordination. There is likely, therefore, to be wide variation in how this invitation process is managed and delivered. Given the age range (2–16 years) of this group, specific access arrangements may need to take into account the timing of nursery and school compared with simply setting up a ‘one size fits all’-type influenza clinic.
Lack of parental priority
Some parents were very frank about the lack of priority they placed on ensuring that their child was protected by influenza vaccination, despite apparently being aware of the potential benefits:
‘Not really, I actually meant to but did not get round to it, to be honest!’ (P46)
Raising awareness of the importance of influenza vaccination in at-risk groups and the potential consequences of non-vaccination may well influence the priority placed by parents on ensuring that their children are vaccinated.
Issues relating to health beliefs
In contrast to the parents for whom a lack of vaccination represented an apparent lack of parental priority, there was a group of parents who seem to have thought deeply about the issues of vaccination, and their decisions were based on the beliefs that they hold about vaccination. These beliefs related to both the influenza vaccination in particular and vaccination in general, and often related to their experience of media reporting of vaccination ‘scares’:
‘I read the leaflet about it (NHS one I think) and tried to make a balanced judgement based on that info and my own knowledge of my son's health — I chose not to have it. At the end of the day, GPs are always I think going to be faced with parents who for whatever reasons think they know best about their child — whether rightly or wrongly! Media scares about vaccines are hard to shake off, and I think have an impact on one's perception of vaccines in general. So while there's not to my knowledge been anything scary said about the flu jab per se, I still feel a bit uneasy about another vaccine for small bodies. I suppose promoting the positives might help convince some people.’ (P35)
Some parents expressed difficulty in accepting that the vaccination is as important for children with chronic health problems as it is for older people:
‘The focus is more on older … it's difficult to imagine a child getting the flu and being very ill.’ (P19)
‘He has never shown any flu symptoms and we feel that he is young to be starting to give him this kind of injection. Also, we have had experience of older members of the family contracting the flu following the injection and we did not want our son to be at risk.’ (P54)
Concerns were also expressed about the vaccine itself — whether in some way it will make an influenza-like illness more likely or whether it could have an adverse impact on the development of their child's immune system:
‘I suppose with any vaccine whether it has short- or long-term side effects that might not yet be evident, whether it's absolutely necessary, or whether it's better to let their immune systems build up their own defences. Whether it may be one vaccine too many? Vaccine overload, as you hear spoken about in the media — are we doing the right thing or not with all these vaccines?’ (P35)
While no clear evidence exists to support the health beliefs described, they can be understood in a climate of negative media reporting of both influenza vaccination, and vaccination in general. Anecdotal evidence is often more powerful than established evidence; for example, although influenza vaccine is an inactivated vaccine, and it is not possible to contract influenza from the vaccination, this firm belief led one family not to vaccinate their child.