Virtually all participants were female (one was male), as predominately women work at CWCs. All were physicians, except for three nurses. Their time as CVP ranged from 3 to 41 years and they were diverse in their familiarity with parent populations that varied by educational level, ethnic background and motivation of vaccine refusal or delay (e.g., fear of side effects, religious disapproval, general scepticism regarding vaccination and support of anthroposophy or homeopathy).
Four main themes were extracted from the focus group discussions: 1) Perceived responsibility; 2) Attitudes toward the NIP; 3) Organizational factors; and 4) Participants' relationship with parents. Insights gained are summarized below by theme and sub-theme, with relevant comments by participants. To compare CVPs at standard CWCs and those at anthroposophical CWCs, we treat the former as one group, distinct from the latter. The next few sections refer to the standard CVPs, with the anthroposophical view presented in the final section.
Participants spoke extensively about what was expected of them, as CVPs, in relation to recommending vaccinations.
Formal task perception
They were in agreement that implementation of the NIP was a CVP responsibility and they expected their CVP colleagues to support vaccine uptake:
"The duty of a physician at a child welfare centre is to vaccinate."
"You cannot do this job if you do not support the NIP."
Accordingly, participants provided parents with information about vaccines and possible side effects, in conversation supported by brochures, usually during the first home visit:
"If parents have questions, I believe you have the obligation to explain. I give them the brochure, so they can read it over."
"In most cases, information about vaccination has already been said at the first home visit before they come at the CWC at 4 weeks for the first office visit."
During the visit at 2 months (when vaccination is scheduled to begin), CVPs verified whether parents had any questions left:
"It is my responsibility to check whether parents have enough information before I vaccinate."
Extra recommendation efforts
The participants recognized that more communication was needed when parents were sceptical about vaccination:
"Some parents doubt or say no because of religious reasons; sometimes you have an extra conversation and I also have a booklet about it, which I give them."
"Nowadays there is a group of parents who are more critical toward vaccination. To them you say: 'Take a brochure, read it carefully and decide afterwards if you want to vaccinate or not. Also take a look at the website of the RIVM, instead of looking only at other critical websites.'"
The participants believed that with parents who were critical toward vaccination, it was their responsibility to ensure that parents made a reasoned decision:
"I always ask their specific reasons for refusing. I believe it is very important that they do not reject it on unfounded grounds."
Some participants recommended making a written inventory of the parents' actual arguments against vaccination:
"If I know their arguments, what their fear is, I will be able to continue from there and explain more about it."
Some participants pursued less discussion with parents who readily accept vaccination:
"Before they visit us for the first time you already know from the home visit whether parents either want to have their child vaccinated or not, and, if I am honest, thereafter little time will be spend talking about the topic if they are accepting."
Attitudes toward the NIP
Overall, participants were positive about the NIP:
"I tell parents how useful the program is, it is so important; all childhood diseases of a number of years ago have disappeared."
Still, they strongly expressed reservations about projected changes to NIP that might affect their intention to recommend vaccinations:
"If you have doubts yourself about a vaccine, it will become very difficult to be convincing in your information towards parents who are expressing their doubts."
Current and future vaccines
Regarding NIP vaccines, participants' main criterion was that the target disease should have a high disease burden. They believed that vaccines in the current program for children of 0-4 years old largely met this criterion. However, concerns were expressed about plans to expand the program to diseases with a relatively low perceived burden:
"With the current NIP I do not have that feeling, i.e., doubts as to persuading parents, but I would have that feeling with the vaccine against human papillomavirus and also with varicella. If varicella vaccination would be introduced, I do not know how I should sell this to the parents."
"Chickenpox is not a serious disease in children. It only gives problems for a few children who belong to a risk group and I wonder whether we should vaccinate the whole population."
Participants were uniformly positive about the extension of hepatitis B vaccine (combined with the DTaP/IPV-Hib vaccine) from high-risk groups to all children, which occurred after the study period:
"We are positive about extending hepatitis B vaccination to all children."
"It makes it for the CVPs more clear and orderly... It becomes easier for us."
"It is now also a bit unfair, i.e., its previous limitation to risk groups."
Participants agreed that vaccine safety was a big point of concern among some parent groups and that side effects were much discussed with parents:
"But the threat of side effects plays an important role for parents who are looking for it."
Side effects I always explain beforehand. Then it does not come so unexpected."
Participants discussed experiences with side effects and safety but agreed that the problem was less worrisome for them than for parents:
"Apparently, side effects are not the first thing we think about."
"Maybe we see side effects as mild compared to parents and their children."
Two injections per consult seemed to be the limit for the participants:
"Otherwise you should vaccinate almost at every consult."
"How many injections can that small body tolerate?"
The NIP schedule was valued for being clear, which reduces the chance of errors and makes it easy to explain to parents. Participants differed about program flexibility: whether or how much the schedule might be adapted to individual cases. Some adhered more strictly to the recommended schedule:
"This is the program: you participate or you do not participate. I would not spend too much time on that in talking to parents."
Others provided examples of delayed vaccination:
"Well, you do have parents who believe 2 months is too young to vaccinate; then I say wait for 1 month, think it over."
Some spread out the injections to one per consult, avoiding more than one at a time:
"For example, one consult for DTaP-IPV and another for pneumococcal vaccine and not simultaneously."
Some participants offered parents the opportunity to come back if parents wanted to revise their decision on vaccine refusal:
"Parents are happy when they do not have to decide today. Even if they say no in the first place, if they decide to vaccinate 2 months later, they are still welcome."
Organizational factors were defined as the environment of participants, which could facilitate or hinder their recommending vaccinations to parents.
Time and other practical considerations
Participants mentioned that CWC consults offered little time to discuss vaccinations with parents:
"Vaccination costs more than the estimated 2.5 min in a consult of 15 min and is not feasible, especially if you need to convince parents about the benefits of vaccination."
Other health checks needed to be completed during the consult as well:
"You just cannot do it all; it is a matter of making choices."
In addition, participants discussed practical constraints that could lead to making mistakes:
"There are many changes, so you might have two types of MMR vaccines in the refrigerator."
"Those hard-to-read packages are irritating anyway!"
"We also regularly have vaccinations with an expired date; this I also do not understand."
Participants felt they did not always receive timely and objective information from NIP in order to respond adequately to parents' arguments and questions about new or revised vaccination:
"With Hepatitis B this has happened: there was no information about it. I visited a congress and knew I would be alright, but there were a lot of colleagues who thought, 'Next month I have to administer the vaccine and then what should I tell parents?'"
Nor were they told about new regulation and protocols:
"I believe that we are badly kept posted about it. As of first of January 2010, the Haemophilus influenzae type B vaccine is not given anymore after the age of 2 years, i.e., this CVP had just noticed the change."
Or about pertinent scientific research:
"I expect that we should be kept posted about developments in science" by receiving "objective" information "on time."
CVPs also wanted to know more about "epidemics around us" and events in the news: "I believe this is not a minor detail: three children who died just after vaccination against pneumococcal disease. First you hear the whole story from word-of-mouth and media and thereafter you only hear from RIVM that there is no association."
They also need "knowledge of what can be found on the internet... what has just been on television."
"Somebody from the RIVM should search the internet continuously" and provide timely and up-to-date information on both sides of a problem:
"That is the balanced information that you want to receive from the RIVM or the government."
Interaction with RIVM
Another factor in participants' intention to recommend vaccinations was related to recognition by the RIVM of CVP expertise:
"We cannot exert influence, they just provide a directive to us, you just have to accept it all, but we do have an opinion about vaccines and changes in the program."
One focus group believed CVPs would be more supportive of NIP if the RIVM showed more interest in their arguments and expertise:
"You want to be taken serious as a professional, particularly because you directly experience problems related to the program or practice that directly affect the health care you deliver. If you think this is threatened, you wonder, 'Are we still recognized by RIVM?'"
Some participants felt poorly informed about NIP changes and their context:
"Now, if there are epidemics around us, then the news reaches us very slowly. This can also be due to our executive physician at the CWC, who should forward it to us."
"I believe that we should be informed directly about big changes in the vaccination program."
Several participants who had contacted immunization administration services regarding non-standard situations, like alternative schedules, perceived some inconsistency:
"If you make a call, what you are told to do depends on who is on the phone... Some are being very pragmatic, while others stick to the rules."
CVP relationship with parents
Establishing a trustful doctor-patient relationship was mentioned as the basis to provide effectively the complete package of care offered at CWCs, including vaccines:
"I believe it is very important that parents have the feeling that the CWC is not only the NIP. If they do not want vaccinations, then maybe you should leave it at that, during the first consult, then continue with it later on. Most important is to establish a trustful relationship so that aside from vaccination a child can make use of the health care provided."
Parental types and attitudes
Participants' recommendation practices seemed to be partly determined by perceived types of parents. Several sub-populations of parents were discussed, with most of them accepting the NIP, including migrant parents:
"I noticed that most parents find vaccinating a very logical thing to do."
"Most migrant parents just do it because the doctor says so."
Many parents did not make a deliberate choice but accepted vaccination out of habit:
"Many parents do not think about it, they just do it."
Some mistakenly believe it is mandatory:
"They say, 'Oh, it's not obligated?'"
Some parents have reservations about vaccinations due to contradictory media messages; usually they were concerned about current and future side effects:
"They are afraid of what might happen: 'Will they not say after 20 years that the substance was causing cancer?'"
Other sceptical parents are members or followers of an association critical toward vaccination:
"I believe most critical parents are highly educated, difficult to drive an argument home to, having an own opinion but not always reading the scientific literature."
Others refuse vaccination based mostly on religious grounds or homeopathic grounds:
"But in L. we of course have Reformed Christians, who do not want to vaccinate."
Here we have believers in classical homeopathy, which is a special group for which a CWC provides the vaccine in a sealed phial. They take the sealed phial for the homeopathist or they do not want to vaccinate at all."
"Now, some of them are very convinced, while others can be persuaded."
Respect and empathy
Participants believed that they should always respect parents' arguments and their choice to vaccinate their child or not:
"You do not need to have the same opinion to show respect."
"Making parents feel welcome irrespective of their choice of vaccination, while showing that you are positive towards the NIP."
Some participants used terms like "motivating" when talking about their way of communicating with parents:
"Motivating is especially one of our tasks."
They stressed the importance of showing empathy towards the arguments of the fearful or sceptical parent:
"I believe that it should start with that: showing empathy towards parents who are afraid of this."
Showing empathy was not always easy, particularly with some arguments or parental attitudes. For example:
"If it is nonsense what the parents are talking about, for example, about autism after MMR vaccination."
"If you indeed feel some hostility, such as 'You do not have to tell me anything.'"
With parents having only moderate concerns about vaccination, participants felt quite competent to establish trust:
"It is just a matter of separating facts and fiction."
"Listening, showing empathy and then discussing your arguments; this will always do."
However, convincing parents was not always possible:
"I have never succeeded to convince somebody who refused vaccination because of religious reasons, despite my efforts."
Communication with members or followers of an association critical towards vaccination was described as difficult and usually ineffective, partly due to parents' closed attitude towards CVPs' information:
"Even facing a close attitude, I always allege in defence of the program."
To some parents who wanted an alternative schedule, an anthroposophical CWC was suggested:
"I also refer to the anthroposophical CWC... Per year, this is 3 times and sometimes 4."
Anthroposophical view on recommending the NIP
Participants in the anthroposophical focus group were willing to adapt the NIP schedule if requested by the parents, a practice less common at most standard CWCs:
"If they want something else, then we will discuss what is possible. We will not immediately say that this is not allowed."
"Implementing the NIP is the best thing to do from a population view, but they are sitting here as a mother; they have to think what is the best for their child."
Our anthroposophical participants offered parents more elaborate information about vaccines, compared to participants at standard CWCs:
"It is my task to inform them very well; with that information they have to take a decision."
"At the regular CWC, they just say: 'Madam it is time to give the second injection' and the injection needle is already in action, i.e., a humorous exaggeration. Consequently, there is no discussion; then parents visit us with the feeling:'I do not want to vaccinate at all anymore.'"
They described their parent population as diverse, but in general their parents have a more critical attitude towards the NIP than those visiting a standard CWC:
"We are a type of safety net for very critical parents."
"In general they are highly educated, but even if not, they have very well-considered thoughts about their health."
Participants reported parental worries about vaccine safety and, on the other hand, the consequences of not vaccinating their child:
"They have fear for the disease the child could get, fear for side effects, and fear for adapting the schedule."
The participants mentioned that conversations about adapting the program could take a lot of time:
"Most parents do not ask about adaptation, but given those who do our population requires a lot of extra time."
Anthroposophical CVPs saw combined vaccines as restricting the possibilities of flexible implementation of NIP:
"I believe especially flexibility, i.e., more than any other factor, would help parents to choose much easier with regard to several vaccinations."
These participants advocated for continued accessibility to certain monovalent vaccines. Like the other participants, they stressed the importance of a clear scientific basis for any decision to introduce new vaccines. Such a decision should particularly consider the severity of vaccine target diseases. In their view, the pharmaceutical industry and economic considerations sometimes had a strong influence on NIP policy:
"It is not the public servant who decides; it is the pharmaceutical company that develops something whether or not anyone asked for it, and then the public servant says: 'Hey, there is something we might as well use.'"
Another anthroposophical view was that RIVM brochures should not use fear to convince the public to accept vaccination:
"What strikes me is that in general the RIVM language makes people afraid of a disease and then says: 'But we have a vaccine for this; you do not have to be afraid anymore.'"