Issues in Comprehensive Pediatric Nursing, 2014; 37(4): 235–249 ß Informa Healthcare USA, Inc. ISSN: 0146-0862 print / 1521-043X online DOI: 10.3109/01460862.2014.951131
MATERNAL CONCERNS ABOUT IMMUNIZATION OVER 0–24 MONTH CHILDREN: A QUALITATIVE RESEARCH
Marjan Delkhosh, MSc, PhD1,2,3, Reza Negarandeh, PhD4, Elham Ghasemi, MSc4, and Hossein Rostami, MSc5 1 Department of Disaster Public Health, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, 2Department of Disaster and Emergency Health, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran, 3Department of Community Health Nursing, School of Nursing & Midwifery, Tehran University of Medical Sciences, Tehran, Iran, 4Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, Iran, and 5Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
The purpose of this qualitative study was to determine the concerns of mothers referred to health center in south Tehran, Iran about immunizing children aged 0–24 months. Data were collected using individual semistructured interviews and analyzed using content analysis. The mothers’ concerns over immunizing their children fell into 5 main categories: (1) ‘‘Factors that cause mothers’ concerns,’’ (2) ‘‘Factors that influence mothers’ concerns,’’ (3) ‘‘Information, education, and communication barriers,’’ (4) ‘‘Informational/educational needs and sources,’’ and (5) ‘‘The necessity of childhood vaccinations.’’ According to study findings, mothers consider immunizing children important and they have enough trust in the health system. A deep understanding of maternal concerns about immunizing their children at 0–24 months allows nurses to reduce mothers’ concerns by removing communication barriers and providing appropriate and adequate information. Keywords: Content analysis, immunization, maternal concerns, Iran
Received 11 May 2014; revised 15 July 2014; accepted 30 July 2014
Correspondence: Elham Ghasemi, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, East Nosrat St., Tohid Sq., Tehran, Iran. Tel: +98(21)66421685. E-mail: [email protected]
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INTRODUCTION Although new drugs have led to significant success in controlling and treating infectious diseases, these diseases are still a threat to human health, so their prevention remains particularly important. In this regard, immunization has a key role and in some cases, vaccines are the only effective weapon against infectious diseases (Rezaipour et al., 2004). Childhood immunization is significantly effective in eliminating and reducing common diseases (Sanford et al., 2007). Although successful immunization programs partly remove fear for the parents concerned about their children becoming infected with serious and fatal diseases, their concerns over the safety of vaccines could influence the use of public immunization programs (Salmon et al., 2009). Concerns about the side effects of vaccines are growing as the incidence of preventable diseases declines due to immunizations (Freed et al., 2010; Gellin, Maibach, & Marcuse, 2000). Although immunization is the primary prevention of many infectious diseases, there are some objections (Borra`s et al., 2009). Negative perception of immunization complications by parents is the main obstacle to childhood immunizations (Heininger, 2006). Reduction or loss of public trust in vaccine safety can lead to lower levels of childhood immunization and reappearance of vaccine-preventable diseases (Freed et al., 2010; Gellin et al., 2000). Nowadays, misguided safety concerns in some countries have led to decreased vaccinations, causing the re-emergence of some infectious diseases (Andre et al., 2008). Fear of child injury, doubt about the accuracy of information on the vaccines (provided by the health system personnel), uncertainty about the safety of vaccines, and the potential risk associated with immunization are factors that reduce parents’ acceptance of immunization (Benin et al., 2006; Heininger, 2006). The study by Bardenheier et al. (2004) revealed that despite some parents’ belief in childhood immunization, many of them were worried about the health and safety of vaccines. In the study by Luthy et al. (2009), concerns over immunization were reported by parents, and child pain, crying, or anxiety were their most common reasons for late immunization of their children. Several studies demonstrated that parent’ attitudes toward vaccination would influence immunization behaviors, such as late or no vaccination of the child (Gust et al., 2004; Paulussen et al., 2006). The Expanded Program on Immunization (EPI) in Iran started as a vertical project in early 1983. It has been an integrated part of the Primary Health Care program (PHC) since 1984. This program covers pregnant women and all children less than 6 years of age, free of charge
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(World Health Organization, 2006; Zahraei et al., 2011). Up to 90% of the rural population has access to PHC services delivered in Health Houses and Rural Health centers. Therefore immunization of children is accessible to most of the urban and rural population. Educating the public, facilitating access, and passing laws required for compulsory vaccination of children (such as not admitting unvaccinated children to schools) have led to an immunization level higher than 98% for children less than 6 years of age in Iran (Gouya et al., 2011). As a member of global surveillance network for adverse effects following vaccine administration, Iran has implemented a monitoring system for immunization safety and adverse events following immunization (AEFI) (Gouya et al., 2011). Although vaccination coverage has reached an acceptable level, ignoring parental concerns over vaccinating their children could threaten this achievement. The aim of this study was to determine the concerns of mothers referred to health centers in south Tehran over immunizing 0–24 month-old children. METHODS A qualitative exploratory study was used to identify mothers’ concerns about childhood immunization. Researchers preferred this method because there was little knowledge about this issue. In this study, which lasted 17 months (July 2011 to November 2012), participants were 26 mothers who had at least one 0–24 month old child and were referred to the vaccination section of health centers affiliated with Tehran University of Medical Sciences (Tehran, Iran) in south Tehran for their child’s vaccination. Participants were selected based on the maximum variety principle (in variables such as age, education, occupation, economic level, and number of children) using non-probability and purposive sampling methods. Data were collected using individual in-depth semi-structured interviews. Semi-structured interview is a qualitative method of inquiry that combines a pre-determined set of open questions (questions that prompt discussion) with the opportunity for the interviewer to explore particular themes or responses further (Arksey & Knight, 1999). The interview guide was designed to allow the extraction of mothers’ special concerns over their children’s immunization. The interview framework included some key questions, and questions were changed if needed according to the interview flow, participant responses, or further analysis of the responses and experiences. The main questions of guide were: [1] Do you have any special concern about your child being immunized? [2] What are the reasons for
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your concern? [3] What reduces your concern? [4] Despite such concerns, why do you still vaccinate your child? The participants were encouraged to explain their concerns and speak freely about other immunization-related issues that were not included in the interview guide. Interviews were conducted in vacant rooms of health centers. Sampling continued until data saturation was achieved (in other words, until data analysis didn’t show any new code). All interviews were tape-recorded and transcribed with the permission of the participants. Data were analyzed using conventional content analysis. This approach is used in qualitative studies aimed at deeply describing a phenomenon. Analysis, categories, and concepts were extracted directly from the data using an inductive method. Thus, each interview was transcribed, noting non-verbal communications of participants such as crying, smiling, sighing, and silence immediately after performance. Interview texts were reviewed several times and statements not related to the study were excluded. Then data were broken into meaning units (sentences and paragraphs). Meaning units were reviewed several times and appropriate codes were written. Codes were classified based on similarities in their concept and meaning, and were abstracted as much as possible. Then, the main categories/themes which were more general and conceptual, emerged. Finally, codes, subcategories, categories, and themes were organized in a hierarchical structure and main concerns of mothers over their children’s immunization were identified. Ethical Consideration The research project was reviewed and approved by the Ethics committee of Tehran University of Medical Sciences. Official permission was obtained for entering the field and carrying out the study. Ethical subjects of interest included protection of the autonomy, confidentiality, and anonymity of the participants during the study. All the participants were informed about the objective and the design of the study and were assured of being able to exit the study unconditionally at every stage of it. Permission for recording the interview was obtained from every participant. In addition, they were asked to read and sign the informed consent form. Interviews were performed after the participants received services in order to show they were not obligated to participate in research to receive services. RESULTS The mean age of interviewees was 29 years old. Most of the participants held high school degrees and were housewives with moderate
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economic levels. They had on average two children with a mean age of 15 months. The findings of the study are presented in five general categories. Factors That Cause Mothers’ Concerns The most important factor that caused mothers’ concern was their fear of unwanted side effects from immunization. Among the problems mentioned by mothers, risk of ‘‘febrile seizures’’ after the immunization was the greatest and the most important concern. In this case, Participant 3 stated: At the time of vaccination, I was worried about fever and seizures. I was more worried about fever. My child is the same age as the child of my sisterin-law. I asked her, but still, I was worried that my child would catch fever and it would become problematic .. . .
‘‘Pain and swelling at the injection area,’’ ‘‘measles-like symptoms,’’ and ‘‘shortness of breath’’ were the other complications that were mentioned as concerns with less frequency. Factors That Influence Mothers’ Concerns Lack of Experience and Knowledge Among the factors that increase mothers’ concern is ‘‘lack of experience and knowledge.’’ This was true of mothers referred to health centers for vaccination of their first child or the first vaccination of their child at 2 months. These mothers usually had little experience or knowledge about vaccination, which increased their concern. In this case, Participant 8 stated: The first time my child was vaccinated, I had no experience. It made me feel anxious. Of course I had enough self-confidence . . . but no experience .. . . I did not know about it .. . . The second vaccination also had some difficulties but others were done well. Now I have adequate experience and information .. . . My anxiety was due to the first vaccination of my first child .. . . now I have enough experience to not fear as much as before . . . my fear is reduced .. . . Experience is so important.
Inappropriate Informing ‘‘The way of providing information by the health center personnel and particularly by the vaccinators’’ was another factor that increased
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concerns. In other words, vaccinators providing more education and explanation than usual or providing it in an inappropriate or non-systematic way, regardless of the mothers’ education level and perception, could significantly increase mothers’ concerns. For example, Participant 15 stated: They scared me a lot .. . . they said ‘‘be careful . . . your child should not be sleepy after vaccination and if your child faints, go to the doctor quickly.’’ I was afraid because of this. I thought they may know and say something I do not know . . . I was afraid too much.
Previous Negative Experience It was found that mothers that had a previous negative experience of a child’s immunization or mothers who have seen or heard (right or wrong statements) about such complications in other children had more concerns in this regard. In this case, Participant 12 stated: I have heard that children catch fever after vaccination, they have pain, and the injection area swells. Well, we hear these things from others . . . these things cause stress. People say, ‘‘Child vaccination gets you into a lot of trouble . . . lots of things will happen . . . your child will get fever, cry, and be restless.’’ I had prepared myself to face lots of problems. But, thanks God! Nothing happened!
Participant 21 stated: I have heard that severe fever causes seizures . . . and other things like this . . . but I have never seen them before, until the son of my sister-in-law got a severe fever followed by seizures. Since then, I am afraid .. . .
Child Vaccination at Certain Ages Child vaccinations at certain ages (according to the Vaccination Schedule of Iran), especially 6 or 12 months, made mothers feel more anxious. This feeling also originated from a heard, seen, or experienced side effect which could cause the vaccination in these ages to be more difficult than at other ages. In this case, Participant 3 stated: Because my first brother’s child had seizures several times, I was afraid that seizures would occur in my child, too. After that, seizures occurred in my
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second brother’s child twice. Other people also talked to me about it. Some people said ‘‘the seizures certainly occur in 6-month-old children.’’ These things increased my fear and anxiety . . .
False Beliefs False beliefs about vaccines and vaccination, such as ‘‘the belief of vaccination difficulty’’ or ‘‘belief of child paralysis after receiving the polio vaccine,’’ were other factors increasing mothers’ concern. In this case, for example, Participant 16 said, ‘‘The vaccination is dangerous. It is not like a common cold and it is risky.’’ Factors That Decrease Mothers’ Concerns Gaining Experiences and Knowledge One of the factors that reduced and controlled mothers’ concerns was ‘‘experiences and knowledge obtained during previous visits or from immunization of their elder children.’’ Giving Information One of the other factors found to decrease mothers’ concern was ‘‘information and guides provided by the health center personnel’’ (about possible complications and ways to control them, care required after vaccination, vaccination schedule, and the proper time for their next referral). If a mother felt that she was able to care for her child and therefore prevent or control the complications by gaining experience or receiving appropriate information and knowledge, her concern would decline. In this case, Participant 8 stated: My fear and anxiety is less than before because I have more experience now . . . difficult steps ended .. . . I have enough experience and knowledge . . . for example, I know that I should dress my child more than ever after vaccination . . . or acetaminophen should be used when fever occurs .. . .
Getting Help ‘‘Attendance of another person at the time of immunization,’’ ‘‘getting help from others or their attendance after immunization,’’ and ‘‘getting help from God and religious beliefs,’’ also decreased mothers’ concerns.
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Trust ‘‘Having a positive opinion about the health center or its personnel’’ and ‘‘encouraging mothers by the personnel’’ were factors effective at reducing mothers’ concerns. Information, Education, and Communication Barriers Health center personnel, particularly the vaccinators, were the main sources for educating mothers about their child’s vaccination. Mothers’ statements indicated that there were significant barriers to receiving training from these people. Inappropriate Behavior of the Vaccinators with Mothers Inappropriate behavior by the vaccinators with mothers was the most significant communication barrier. In some cases, it was so serious that mothers preferred not to ask questions due to fear of inappropriate behaviors of the vaccinators. In this case, Participant 2 stated: When I am at home, I have lots of questions all of which I want to ask . . . but when I come here (health center), I forget all of them . . . because I am afraid . . . afraid of personnel . . . even I do not remember what I wanted to ask . . .
Education Failure and Insufficiency This item was the other important educational barrier. In this regard, two general items of ‘‘failure to provide adequate education’’ and ‘‘failure to provide simple, clear, and understandable explanations’’ were identified. Failure to provide understandable explanations for mothers considering their education levels was a factor which not only did not decrease concerns, but also increased them. Feeling Shy or Ashamed Sometimes the barrier of receiving adequate information was related to specific characteristics in mothers such as ‘‘feeling shy or ashamed’’ which stopped them from asking question. In this case, Participant 15 stated: I do not ask questions . . . I do not dare to ask questions . . . I always follow the instructions of the doctors and do what they say . . . because I feel embarrassed to ask any questions.
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Impatience of Vaccinators ‘‘Impatience of vaccinators’’ was determined to be another communication barrier. In this regard Participant 23 stated: Because they are impatient in responding to our questions, I do not ask them my questions . . . I prefer to ask someone else . . . if they had patience, they would inform us about necessary things .. . . At these times, some of them do not answer anything, do not say anything . . . or even speak with their colleagues .. . .
Being too Busy and Having no Time ‘‘Being too busy and therefore having no time to respond to the questions’’ or ‘‘responding rapidly to the questions’’ were the other educational and communicational barriers between health center personnel and mothers. Participant 12 stated: The vaccinator was a little impatient . . . answered the questions very quickly. Someone like me may understand what they said but an uneducated person or a person who has elementary education could not understand what they said! . . . they may need to ask something two or three times to understand it . . . but unfortunately, they respond very quickly . . .
Participant 2 stated: They are too busy . . . and also their behavior is not good enough. Many people complain that the personnel do not answer our questions properly.
Child Crying and Restlessness Child crying and restlessness was another education and communication barrier. Informational/Educational Needs and Sources Interviews revealed that many mothers had questions about their child’s vaccination. For example, they wanted to know about ‘‘possible complications of vaccination and the ways of dealing with . . . them,’’ ‘‘care requirements after vaccination,’’ and in some cases about ‘‘the vaccines and their nature or function.’’ The most important source which met their educational needs was ‘‘health center personnel and vaccinators.’’ The next source included people such as ‘‘their parents, like mothers and
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mothers-in-law,’’ ‘‘family members and relatives,’’ and ‘‘neighbors,’’ or people who had ‘‘children’’ or ‘‘more experience in this relation.’’ Although media, especially radio and television, are the most valuable sources of health information in Iran recently, the interviews showed their limited role in this area. For example, Participant 4 stated, ‘‘I have not heard and seen anything about vaccination on radio or television.’’ ‘‘Books and magazines,’’ ‘‘pediatrician,’’ and ‘‘other educated people’’ were educational sources that were mentioned less by mothers. The Necessity of Vaccination Almost all of the mothers believed that vaccination is necessary for ‘‘child health’’ and helps to prevent disease, especially dangerous diseases. Some of them referred to it as a ‘‘vital’’ and ‘‘legal’’ thing and believed in its ‘‘goodness.’’ Some of them also mentioned side effects of non-immunization and therefore referred to it as a ‘‘necessity.’’ In this case, Participant 8 stated: Well . . . it is a law . . . the law of vaccination . . . the law must be stable . . .. the child must be vaccinated to be away from many diseases. Law must be stable and the child must be vaccinated to be away from diseases . . .
Finally, in all interviews, ‘‘mothers trust in health system’’ was perceived. In this study, no concern or doubt was observed about vaccine safety, its prescribed dose, method of storage, application of the vaccine with expired date, or accuracy/reliability of the provided information about the vaccination by health centers personnel. DISCUSSION Results showed mothers’ most frequent concern over their child’s immunization was the occurrence of side effects. Among different side effects, the incidence of fever or seizures caused the greatest fear. Parents’ fear and anxiety about severe or life-threatening complications after immunization have been identified among the main barriers to immunization in several studies (Freed et al., 2004, 2010). In some studies, it was found that the fear of possible side effects or child injury due to vaccination was commonly reported by parents, which stopped vaccination in some cases (Freed et al., 2010; Ramezani et al., 2009; Salmon et al., 2009). Other factors increasing mothers’ concerns were ‘‘child crying, restlessness, screaming, and shouting, and having pain after vaccination.’’ Luthy et al. (2009) also reported that parents’ were concerned
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about child immunization causing pain, crying, and restlessness, which led to immunization delay. The study by Freed et al. (2004) identified the most common cause of parental concern as pain and short-term reactions caused by injections. Immunization at certain ages, such as 1 year (the age for the MMR vaccine according to the vaccination schedule of Iran), was the other factor that increased parents’ concerns. Similarly in the study by Smith et al. (2009) it was found that many parents expressed concern about the combined MMR vaccine injection at the age of 1 year. One of the most significant differences between this and other studies is that some studies showed the risk of autism after MMR vaccine injection as one of the major concerns (Brown et al., 2012; Casiday et al., 2006; Downs et al., 2008; Freed et al., 2004; Smith et al., 2009), while it was not observed in this study. This issue could be the result of differences in participants’ knowledge and common beliefs that exist in different societies about possible complications of vaccines. In this study there were mothers who mentioned the ‘‘increase of awareness, experiences, and responsibilities’’ as causes of their concern. In this regard, health care personnel could provide enough and correct information for parents by spending more time with them to review and resolve their concerns. Therefore, in this way, they could help decrease or eliminate parents’ concerns and encourage them to vaccinate their children in a timely manner. Also, their beliefs may contribute to parental decisions to accept, delay, or forgo vaccinations (Mergler et al., 2013). In this study, it was revealed that mothers who had experience with vaccination complications in their child or heard something about it (true or not) expressed more concerns. False narratives or quotes may have a negative effect on public beliefs in vaccination, leading to a significant future decline in immunization coverage (Paulussen et al., 2006). Several studies have also demonstrated that parent attitudes toward and beliefs in vaccination would influence immunization behaviors, such as late or no vaccination (Gust et al., 2004; Paulussen et al., 2006). According to the results of Fredrickson et al. (2004) on a sample of 544 parents in America (32 groups from 6 cities), parents’ fear of the side effects they had heard from the media and other people was the most common reason for refusal of their child’s vaccination (Fredrickson et al., 2004). It was found that the most important information source for parents that met their educational needs about child vaccination was health center personnel, and particularly the vaccinators. There is a unique opportunity for nurses, doctors, and other providers of primary health care to educate parents, since the parents accept them as the most important sources of information about child vaccination (Gellin et al.,
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2000; Jones et al., 2012; Vorsters et al., 2010). The results of studies by Bavarian et al. (2003), and Luthy et al. (2009) also confirm this finding. On the other hand, lack of information is directly associated with increase of parental concerns and their anxiety in many areas of health care. Health center personnel providing incomplete or wrong information accompanied negative attitudes of parents towards immunization and health care providers (Bradley, 1999). In the study by Gust et al. (2008), it was found that although a majority of parents were reluctant for their child to receive vaccines due to their doubt about vaccination and its possible side effects, these parents changed their minds after receiving information and gaining assurance from health care providers. In some studies, it was shown that health care providers could have a positive impact on parents’ decisions about their child’s immunization, particularly parents who believe that vaccines may be unhealthy or unsafe (Smith et al., 2006). Therefore, as the vaccinators are the most important and available source of information for parents, they could help decrease or eliminate parents’ concerns in this regard. In this study, although the interviews showed the limited role of media, especially radio and television, in providing health information, they are one of the most valuable sources of providing information in this area. Ultimately, considering all interviews, mothers’ trust in the health system was found in vaccine health, safety, prescribed dose, storage ways, date, and accuracy/validity of training provided by health centers personnel. The study by Salmon et al. (2009) revealed that parents who had completely vaccinated their child trusted health care personnel as well as government advice more than those who had partially vaccinated their child. In the study by Shui and colleagues (2005), it was found that the main reasons for mothers’ concerns about their child’s immunization were ‘‘doubt about vaccine safety and necessity,’’ ‘‘lack of trust in medical community,’’ and ‘‘lack of information.’’ Therefore, considering the importance of trust in relationships between parents and health care system personnel as well as the possible benefits of this trust in promoting vaccination and good health, the health system should try to build, keep, and promote this trust. In this regard, providing required training about child immunization for parents as well as providing required training on the importance of this issue for health care system personnel would improve both group participation and expansion of immunization coverage. Given the importance of issues such as communication and providing appropriate information to resolve parents’ concerns, further study of the communication barriers between parents and concerned personnel (vaccinators) is recommended. Additional studies could gather information on the impact on immunization status of children and the impact of
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effective interpersonal and educational communication between parents and health care personnel on reducing parents’ concerns. Limitations As this research was conducted on mothers who were referred to public health centers to immunize their children, our findings do not represent the concerns of all levels of the society. The interview circumstance was the other limitation of the study. For example, crying, restlessness/ agitation, and playfulness of children led to loss of mothers’ concentration or devoting less time to do the interview. Cultural and ethnic variation and different accents (especially in relation to Afghan participants) made some semantic barriers and interfered with complete understanding of their responses, which was greatly resolved by frequent listening to the interview tape recordings and getting help from local personnel. CONCLUSION A part of health care officials’ success in immunization programs depends on controlling parents’ concerns over their child’s vaccination, which requires careful planning and regular monitoring and increasing of parents’ education by health care system personnel. Therefore, health care personnel have to be educated and prepared to deal with concerns, questions, or negative attitudes of parents towards their child’s vaccinations. In this regard, it is necessary to have a complete and correct perception of parents’ concerns, their communication problems, and ways of providing appropriate information about vaccination. The present study has provided essential data in these areas. ACKNOWLEDGMENT We gratefully acknowledge the parents who participated in interviews. DECLARATION OF INTEREST This study was approved and funded by the Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences (Grant No. 11497). REFERENCES Andre, F. E., Booy, R., Bock, H. L., Clemens, J., Datta, S. K., John, T. J., Lee, B. W., Lolekha, S., Peltola, H., Ruff, T. A., Santosham, M., Schmitt, H. J. (2008).
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Jones, A. M., Omer, S. B., Bednarczyk, R. A., Halsey, N. A., Moulton, L. H., & Salmon, D. A. (2012). Parents’ source of vaccine information and impact on vaccine attitudes, beliefs, and nonmedical exemptions. Advances in Preventive Medicine, 2012, 1–8. Kimmel, S. R., Burns, I. T., Wolfe, R. M., Zimmerman, R. K. (2007). Addressing immunization barriers, benefits, and risks. The Journal of Family Practice, 56, S61–S69. Luthy, K. E., Beckstrand, R. L., & Peterson, N. E. (2009). Parental hesitation as a factor in delayed childhood immunization. Journal of Pediatric Health Care, 23, 388–393. Mergler, M. J., Omer, S. B., Pan, W. K., Navar-Boggan, A. M., Orenstein, W., Marcuse, E. K., et al., Damico, A. (2013). Association of vaccine-related attitudes and beliefs between parents and health care providers. Vaccine, 31, 4591–4595. Paulussen, T., Hoekstra, F., Lanting, C., Buijs, G., & Hirasing, R. (2006). Determinants of Dutch parents’ decisions to vaccinate their child. Vaccine, 24, 644–651. Ramezani, A., Miri, M., Hanafi, M., & Zangooi, H. (2009). Evaluation of the Impact Vaccination Program among children and mothers in Southern Khorasan Province in 2005. Iranian Journal of Epidemiology, 5, 27–32. Rezaipour, A., Granmayeh, M., Kazemnejad, A., & Hajizadeh, S. (2004). Assessment of expanded program on immunization for mothers and children under 2 years old in Shahriar. Hayat, 10, 52–62. Salmon, D. A., Sotir, M. J., Pan, W. K., Berg, J. L., Omer, S. B., Stokley, S., Davis, J. P., Halsey, N. (2009). Parental vaccine refusal in Wisconsin: a case-control study. Wisconsin Medical Journal (WMJ), 108, 17–23. Shui, I., Kennedy, A., Wooten, K., Schwartz, B., & Gust, D. (2005). Factors influencing African-American mothers’ concerns about immunization safety: a summary of focus group findings. Journal of the National Medical Association, 97, 657–666. Smith, M. J., Woods, C. R., & Marshall, G. S. (2009). Parental vaccine concerns in Kentucky. The Journal of the Kentucky Medical Association, 107, 342–349. Smith, P. J., Kennedy, A. M., Wooten, K., Gust, D. A., & Pickering, L. K. (2006). Association between health care providers’ influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics, 118, e1287–e1292. Vorsters, A., Tack, S., Hendrickx, G., Vladimirova, N., Bonanni, P., Pistol, A., et al., Aronsson, B. (2010). A summer school on vaccinology: responding to identified gaps in pre-service immunisation training of future health care workers. Vaccine, 28, 2053–2059. World Health Organization. (2006). Health system profile, Islamic Republic of Iran. Regional health system observatory. Available at: www.who.int.healthobservatory. Zahraei, S. M., Gouya, M. M., Azad, T. M., Soltanshahi, R., Sabouri, A., Naouri, B., & Alexander, J. P. (2011). Successful control and impending elimination of measles in the Islamic Republic of Iran. Journal of Infectious Diseases, 204(suppl 1), S305–S311. Notice of Correction: A correction was made to the second affiliation of the first author since the original online publication date of September 4, 2014.
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MATERNAL CONCERNS ABOUT IMMUNIZATION OVER 0–24 MONTH CHILDREN: A QUALITATIVE RESEARCH
Marjan Delkhosh, MSc, PhD1,2,3, Reza Negarandeh, PhD4, Elham Ghasemi, MSc4, and Hossein Rostami, MSc5 1 Department of Disaster Public Health, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, 2Department of Disaster and Emergency Health, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran, 3Department of Community Health Nursing, School of Nursing & Midwifery, Tehran University of Medical Sciences, Tehran, Iran, 4Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, Iran, and 5Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
The purpose of this qualitative study was to determine the concerns of mothers referred to health center in south Tehran, Iran about immunizing children aged 0–24 months. Data were collected using individual semistructured interviews and analyzed using content analysis. The mothers’ concerns over immunizing their children fell into 5 main categories: (1) ‘‘Factors that cause mothers’ concerns,’’ (2) ‘‘Factors that influence mothers’ concerns,’’ (3) ‘‘Information, education, and communication barriers,’’ (4) ‘‘Informational/educational needs and sources,’’ and (5) ‘‘The necessity of childhood vaccinations.’’ According to study findings, mothers consider immunizing children important and they have enough trust in the health system. A deep understanding of maternal concerns about immunizing their children at 0–24 months allows nurses to reduce mothers’ concerns by removing communication barriers and providing appropriate and adequate information. Keywords: Content analysis, immunization, maternal concerns, Iran
Received 11 May 2014; revised 15 July 2014; accepted 30 July 2014
Correspondence: Elham Ghasemi, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, East Nosrat St., Tohid Sq., Tehran, Iran. Tel: +98(21)66421685. E-mail: [email protected]
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INTRODUCTION Although new drugs have led to significant success in controlling and treating infectious diseases, these diseases are still a threat to human health, so their prevention remains particularly important. In this regard, immunization has a key role and in some cases, vaccines are the only effective weapon against infectious diseases (Rezaipour et al., 2004). Childhood immunization is significantly effective in eliminating and reducing common diseases (Sanford et al., 2007). Although successful immunization programs partly remove fear for the parents concerned about their children becoming infected with serious and fatal diseases, their concerns over the safety of vaccines could influence the use of public immunization programs (Salmon et al., 2009). Concerns about the side effects of vaccines are growing as the incidence of preventable diseases declines due to immunizations (Freed et al., 2010; Gellin, Maibach, & Marcuse, 2000). Although immunization is the primary prevention of many infectious diseases, there are some objections (Borra`s et al., 2009). Negative perception of immunization complications by parents is the main obstacle to childhood immunizations (Heininger, 2006). Reduction or loss of public trust in vaccine safety can lead to lower levels of childhood immunization and reappearance of vaccine-preventable diseases (Freed et al., 2010; Gellin et al., 2000). Nowadays, misguided safety concerns in some countries have led to decreased vaccinations, causing the re-emergence of some infectious diseases (Andre et al., 2008). Fear of child injury, doubt about the accuracy of information on the vaccines (provided by the health system personnel), uncertainty about the safety of vaccines, and the potential risk associated with immunization are factors that reduce parents’ acceptance of immunization (Benin et al., 2006; Heininger, 2006). The study by Bardenheier et al. (2004) revealed that despite some parents’ belief in childhood immunization, many of them were worried about the health and safety of vaccines. In the study by Luthy et al. (2009), concerns over immunization were reported by parents, and child pain, crying, or anxiety were their most common reasons for late immunization of their children. Several studies demonstrated that parent’ attitudes toward vaccination would influence immunization behaviors, such as late or no vaccination of the child (Gust et al., 2004; Paulussen et al., 2006). The Expanded Program on Immunization (EPI) in Iran started as a vertical project in early 1983. It has been an integrated part of the Primary Health Care program (PHC) since 1984. This program covers pregnant women and all children less than 6 years of age, free of charge
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(World Health Organization, 2006; Zahraei et al., 2011). Up to 90% of the rural population has access to PHC services delivered in Health Houses and Rural Health centers. Therefore immunization of children is accessible to most of the urban and rural population. Educating the public, facilitating access, and passing laws required for compulsory vaccination of children (such as not admitting unvaccinated children to schools) have led to an immunization level higher than 98% for children less than 6 years of age in Iran (Gouya et al., 2011). As a member of global surveillance network for adverse effects following vaccine administration, Iran has implemented a monitoring system for immunization safety and adverse events following immunization (AEFI) (Gouya et al., 2011). Although vaccination coverage has reached an acceptable level, ignoring parental concerns over vaccinating their children could threaten this achievement. The aim of this study was to determine the concerns of mothers referred to health centers in south Tehran over immunizing 0–24 month-old children. METHODS A qualitative exploratory study was used to identify mothers’ concerns about childhood immunization. Researchers preferred this method because there was little knowledge about this issue. In this study, which lasted 17 months (July 2011 to November 2012), participants were 26 mothers who had at least one 0–24 month old child and were referred to the vaccination section of health centers affiliated with Tehran University of Medical Sciences (Tehran, Iran) in south Tehran for their child’s vaccination. Participants were selected based on the maximum variety principle (in variables such as age, education, occupation, economic level, and number of children) using non-probability and purposive sampling methods. Data were collected using individual in-depth semi-structured interviews. Semi-structured interview is a qualitative method of inquiry that combines a pre-determined set of open questions (questions that prompt discussion) with the opportunity for the interviewer to explore particular themes or responses further (Arksey & Knight, 1999). The interview guide was designed to allow the extraction of mothers’ special concerns over their children’s immunization. The interview framework included some key questions, and questions were changed if needed according to the interview flow, participant responses, or further analysis of the responses and experiences. The main questions of guide were: [1] Do you have any special concern about your child being immunized? [2] What are the reasons for
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your concern? [3] What reduces your concern? [4] Despite such concerns, why do you still vaccinate your child? The participants were encouraged to explain their concerns and speak freely about other immunization-related issues that were not included in the interview guide. Interviews were conducted in vacant rooms of health centers. Sampling continued until data saturation was achieved (in other words, until data analysis didn’t show any new code). All interviews were tape-recorded and transcribed with the permission of the participants. Data were analyzed using conventional content analysis. This approach is used in qualitative studies aimed at deeply describing a phenomenon. Analysis, categories, and concepts were extracted directly from the data using an inductive method. Thus, each interview was transcribed, noting non-verbal communications of participants such as crying, smiling, sighing, and silence immediately after performance. Interview texts were reviewed several times and statements not related to the study were excluded. Then data were broken into meaning units (sentences and paragraphs). Meaning units were reviewed several times and appropriate codes were written. Codes were classified based on similarities in their concept and meaning, and were abstracted as much as possible. Then, the main categories/themes which were more general and conceptual, emerged. Finally, codes, subcategories, categories, and themes were organized in a hierarchical structure and main concerns of mothers over their children’s immunization were identified. Ethical Consideration The research project was reviewed and approved by the Ethics committee of Tehran University of Medical Sciences. Official permission was obtained for entering the field and carrying out the study. Ethical subjects of interest included protection of the autonomy, confidentiality, and anonymity of the participants during the study. All the participants were informed about the objective and the design of the study and were assured of being able to exit the study unconditionally at every stage of it. Permission for recording the interview was obtained from every participant. In addition, they were asked to read and sign the informed consent form. Interviews were performed after the participants received services in order to show they were not obligated to participate in research to receive services. RESULTS The mean age of interviewees was 29 years old. Most of the participants held high school degrees and were housewives with moderate
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economic levels. They had on average two children with a mean age of 15 months. The findings of the study are presented in five general categories. Factors That Cause Mothers’ Concerns The most important factor that caused mothers’ concern was their fear of unwanted side effects from immunization. Among the problems mentioned by mothers, risk of ‘‘febrile seizures’’ after the immunization was the greatest and the most important concern. In this case, Participant 3 stated: At the time of vaccination, I was worried about fever and seizures. I was more worried about fever. My child is the same age as the child of my sisterin-law. I asked her, but still, I was worried that my child would catch fever and it would become problematic .. . .
‘‘Pain and swelling at the injection area,’’ ‘‘measles-like symptoms,’’ and ‘‘shortness of breath’’ were the other complications that were mentioned as concerns with less frequency. Factors That Influence Mothers’ Concerns Lack of Experience and Knowledge Among the factors that increase mothers’ concern is ‘‘lack of experience and knowledge.’’ This was true of mothers referred to health centers for vaccination of their first child or the first vaccination of their child at 2 months. These mothers usually had little experience or knowledge about vaccination, which increased their concern. In this case, Participant 8 stated: The first time my child was vaccinated, I had no experience. It made me feel anxious. Of course I had enough self-confidence . . . but no experience .. . . I did not know about it .. . . The second vaccination also had some difficulties but others were done well. Now I have adequate experience and information .. . . My anxiety was due to the first vaccination of my first child .. . . now I have enough experience to not fear as much as before . . . my fear is reduced .. . . Experience is so important.
Inappropriate Informing ‘‘The way of providing information by the health center personnel and particularly by the vaccinators’’ was another factor that increased
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concerns. In other words, vaccinators providing more education and explanation than usual or providing it in an inappropriate or non-systematic way, regardless of the mothers’ education level and perception, could significantly increase mothers’ concerns. For example, Participant 15 stated: They scared me a lot .. . . they said ‘‘be careful . . . your child should not be sleepy after vaccination and if your child faints, go to the doctor quickly.’’ I was afraid because of this. I thought they may know and say something I do not know . . . I was afraid too much.
Previous Negative Experience It was found that mothers that had a previous negative experience of a child’s immunization or mothers who have seen or heard (right or wrong statements) about such complications in other children had more concerns in this regard. In this case, Participant 12 stated: I have heard that children catch fever after vaccination, they have pain, and the injection area swells. Well, we hear these things from others . . . these things cause stress. People say, ‘‘Child vaccination gets you into a lot of trouble . . . lots of things will happen . . . your child will get fever, cry, and be restless.’’ I had prepared myself to face lots of problems. But, thanks God! Nothing happened!
Participant 21 stated: I have heard that severe fever causes seizures . . . and other things like this . . . but I have never seen them before, until the son of my sister-in-law got a severe fever followed by seizures. Since then, I am afraid .. . .
Child Vaccination at Certain Ages Child vaccinations at certain ages (according to the Vaccination Schedule of Iran), especially 6 or 12 months, made mothers feel more anxious. This feeling also originated from a heard, seen, or experienced side effect which could cause the vaccination in these ages to be more difficult than at other ages. In this case, Participant 3 stated: Because my first brother’s child had seizures several times, I was afraid that seizures would occur in my child, too. After that, seizures occurred in my
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second brother’s child twice. Other people also talked to me about it. Some people said ‘‘the seizures certainly occur in 6-month-old children.’’ These things increased my fear and anxiety . . .
False Beliefs False beliefs about vaccines and vaccination, such as ‘‘the belief of vaccination difficulty’’ or ‘‘belief of child paralysis after receiving the polio vaccine,’’ were other factors increasing mothers’ concern. In this case, for example, Participant 16 said, ‘‘The vaccination is dangerous. It is not like a common cold and it is risky.’’ Factors That Decrease Mothers’ Concerns Gaining Experiences and Knowledge One of the factors that reduced and controlled mothers’ concerns was ‘‘experiences and knowledge obtained during previous visits or from immunization of their elder children.’’ Giving Information One of the other factors found to decrease mothers’ concern was ‘‘information and guides provided by the health center personnel’’ (about possible complications and ways to control them, care required after vaccination, vaccination schedule, and the proper time for their next referral). If a mother felt that she was able to care for her child and therefore prevent or control the complications by gaining experience or receiving appropriate information and knowledge, her concern would decline. In this case, Participant 8 stated: My fear and anxiety is less than before because I have more experience now . . . difficult steps ended .. . . I have enough experience and knowledge . . . for example, I know that I should dress my child more than ever after vaccination . . . or acetaminophen should be used when fever occurs .. . .
Getting Help ‘‘Attendance of another person at the time of immunization,’’ ‘‘getting help from others or their attendance after immunization,’’ and ‘‘getting help from God and religious beliefs,’’ also decreased mothers’ concerns.
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Trust ‘‘Having a positive opinion about the health center or its personnel’’ and ‘‘encouraging mothers by the personnel’’ were factors effective at reducing mothers’ concerns. Information, Education, and Communication Barriers Health center personnel, particularly the vaccinators, were the main sources for educating mothers about their child’s vaccination. Mothers’ statements indicated that there were significant barriers to receiving training from these people. Inappropriate Behavior of the Vaccinators with Mothers Inappropriate behavior by the vaccinators with mothers was the most significant communication barrier. In some cases, it was so serious that mothers preferred not to ask questions due to fear of inappropriate behaviors of the vaccinators. In this case, Participant 2 stated: When I am at home, I have lots of questions all of which I want to ask . . . but when I come here (health center), I forget all of them . . . because I am afraid . . . afraid of personnel . . . even I do not remember what I wanted to ask . . .
Education Failure and Insufficiency This item was the other important educational barrier. In this regard, two general items of ‘‘failure to provide adequate education’’ and ‘‘failure to provide simple, clear, and understandable explanations’’ were identified. Failure to provide understandable explanations for mothers considering their education levels was a factor which not only did not decrease concerns, but also increased them. Feeling Shy or Ashamed Sometimes the barrier of receiving adequate information was related to specific characteristics in mothers such as ‘‘feeling shy or ashamed’’ which stopped them from asking question. In this case, Participant 15 stated: I do not ask questions . . . I do not dare to ask questions . . . I always follow the instructions of the doctors and do what they say . . . because I feel embarrassed to ask any questions.
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Impatience of Vaccinators ‘‘Impatience of vaccinators’’ was determined to be another communication barrier. In this regard Participant 23 stated: Because they are impatient in responding to our questions, I do not ask them my questions . . . I prefer to ask someone else . . . if they had patience, they would inform us about necessary things .. . . At these times, some of them do not answer anything, do not say anything . . . or even speak with their colleagues .. . .
Being too Busy and Having no Time ‘‘Being too busy and therefore having no time to respond to the questions’’ or ‘‘responding rapidly to the questions’’ were the other educational and communicational barriers between health center personnel and mothers. Participant 12 stated: The vaccinator was a little impatient . . . answered the questions very quickly. Someone like me may understand what they said but an uneducated person or a person who has elementary education could not understand what they said! . . . they may need to ask something two or three times to understand it . . . but unfortunately, they respond very quickly . . .
Participant 2 stated: They are too busy . . . and also their behavior is not good enough. Many people complain that the personnel do not answer our questions properly.
Child Crying and Restlessness Child crying and restlessness was another education and communication barrier. Informational/Educational Needs and Sources Interviews revealed that many mothers had questions about their child’s vaccination. For example, they wanted to know about ‘‘possible complications of vaccination and the ways of dealing with . . . them,’’ ‘‘care requirements after vaccination,’’ and in some cases about ‘‘the vaccines and their nature or function.’’ The most important source which met their educational needs was ‘‘health center personnel and vaccinators.’’ The next source included people such as ‘‘their parents, like mothers and
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mothers-in-law,’’ ‘‘family members and relatives,’’ and ‘‘neighbors,’’ or people who had ‘‘children’’ or ‘‘more experience in this relation.’’ Although media, especially radio and television, are the most valuable sources of health information in Iran recently, the interviews showed their limited role in this area. For example, Participant 4 stated, ‘‘I have not heard and seen anything about vaccination on radio or television.’’ ‘‘Books and magazines,’’ ‘‘pediatrician,’’ and ‘‘other educated people’’ were educational sources that were mentioned less by mothers. The Necessity of Vaccination Almost all of the mothers believed that vaccination is necessary for ‘‘child health’’ and helps to prevent disease, especially dangerous diseases. Some of them referred to it as a ‘‘vital’’ and ‘‘legal’’ thing and believed in its ‘‘goodness.’’ Some of them also mentioned side effects of non-immunization and therefore referred to it as a ‘‘necessity.’’ In this case, Participant 8 stated: Well . . . it is a law . . . the law of vaccination . . . the law must be stable . . .. the child must be vaccinated to be away from many diseases. Law must be stable and the child must be vaccinated to be away from diseases . . .
Finally, in all interviews, ‘‘mothers trust in health system’’ was perceived. In this study, no concern or doubt was observed about vaccine safety, its prescribed dose, method of storage, application of the vaccine with expired date, or accuracy/reliability of the provided information about the vaccination by health centers personnel. DISCUSSION Results showed mothers’ most frequent concern over their child’s immunization was the occurrence of side effects. Among different side effects, the incidence of fever or seizures caused the greatest fear. Parents’ fear and anxiety about severe or life-threatening complications after immunization have been identified among the main barriers to immunization in several studies (Freed et al., 2004, 2010). In some studies, it was found that the fear of possible side effects or child injury due to vaccination was commonly reported by parents, which stopped vaccination in some cases (Freed et al., 2010; Ramezani et al., 2009; Salmon et al., 2009). Other factors increasing mothers’ concerns were ‘‘child crying, restlessness, screaming, and shouting, and having pain after vaccination.’’ Luthy et al. (2009) also reported that parents’ were concerned
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about child immunization causing pain, crying, and restlessness, which led to immunization delay. The study by Freed et al. (2004) identified the most common cause of parental concern as pain and short-term reactions caused by injections. Immunization at certain ages, such as 1 year (the age for the MMR vaccine according to the vaccination schedule of Iran), was the other factor that increased parents’ concerns. Similarly in the study by Smith et al. (2009) it was found that many parents expressed concern about the combined MMR vaccine injection at the age of 1 year. One of the most significant differences between this and other studies is that some studies showed the risk of autism after MMR vaccine injection as one of the major concerns (Brown et al., 2012; Casiday et al., 2006; Downs et al., 2008; Freed et al., 2004; Smith et al., 2009), while it was not observed in this study. This issue could be the result of differences in participants’ knowledge and common beliefs that exist in different societies about possible complications of vaccines. In this study there were mothers who mentioned the ‘‘increase of awareness, experiences, and responsibilities’’ as causes of their concern. In this regard, health care personnel could provide enough and correct information for parents by spending more time with them to review and resolve their concerns. Therefore, in this way, they could help decrease or eliminate parents’ concerns and encourage them to vaccinate their children in a timely manner. Also, their beliefs may contribute to parental decisions to accept, delay, or forgo vaccinations (Mergler et al., 2013). In this study, it was revealed that mothers who had experience with vaccination complications in their child or heard something about it (true or not) expressed more concerns. False narratives or quotes may have a negative effect on public beliefs in vaccination, leading to a significant future decline in immunization coverage (Paulussen et al., 2006). Several studies have also demonstrated that parent attitudes toward and beliefs in vaccination would influence immunization behaviors, such as late or no vaccination (Gust et al., 2004; Paulussen et al., 2006). According to the results of Fredrickson et al. (2004) on a sample of 544 parents in America (32 groups from 6 cities), parents’ fear of the side effects they had heard from the media and other people was the most common reason for refusal of their child’s vaccination (Fredrickson et al., 2004). It was found that the most important information source for parents that met their educational needs about child vaccination was health center personnel, and particularly the vaccinators. There is a unique opportunity for nurses, doctors, and other providers of primary health care to educate parents, since the parents accept them as the most important sources of information about child vaccination (Gellin et al.,
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2000; Jones et al., 2012; Vorsters et al., 2010). The results of studies by Bavarian et al. (2003), and Luthy et al. (2009) also confirm this finding. On the other hand, lack of information is directly associated with increase of parental concerns and their anxiety in many areas of health care. Health center personnel providing incomplete or wrong information accompanied negative attitudes of parents towards immunization and health care providers (Bradley, 1999). In the study by Gust et al. (2008), it was found that although a majority of parents were reluctant for their child to receive vaccines due to their doubt about vaccination and its possible side effects, these parents changed their minds after receiving information and gaining assurance from health care providers. In some studies, it was shown that health care providers could have a positive impact on parents’ decisions about their child’s immunization, particularly parents who believe that vaccines may be unhealthy or unsafe (Smith et al., 2006). Therefore, as the vaccinators are the most important and available source of information for parents, they could help decrease or eliminate parents’ concerns in this regard. In this study, although the interviews showed the limited role of media, especially radio and television, in providing health information, they are one of the most valuable sources of providing information in this area. Ultimately, considering all interviews, mothers’ trust in the health system was found in vaccine health, safety, prescribed dose, storage ways, date, and accuracy/validity of training provided by health centers personnel. The study by Salmon et al. (2009) revealed that parents who had completely vaccinated their child trusted health care personnel as well as government advice more than those who had partially vaccinated their child. In the study by Shui and colleagues (2005), it was found that the main reasons for mothers’ concerns about their child’s immunization were ‘‘doubt about vaccine safety and necessity,’’ ‘‘lack of trust in medical community,’’ and ‘‘lack of information.’’ Therefore, considering the importance of trust in relationships between parents and health care system personnel as well as the possible benefits of this trust in promoting vaccination and good health, the health system should try to build, keep, and promote this trust. In this regard, providing required training about child immunization for parents as well as providing required training on the importance of this issue for health care system personnel would improve both group participation and expansion of immunization coverage. Given the importance of issues such as communication and providing appropriate information to resolve parents’ concerns, further study of the communication barriers between parents and concerned personnel (vaccinators) is recommended. Additional studies could gather information on the impact on immunization status of children and the impact of
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effective interpersonal and educational communication between parents and health care personnel on reducing parents’ concerns. Limitations As this research was conducted on mothers who were referred to public health centers to immunize their children, our findings do not represent the concerns of all levels of the society. The interview circumstance was the other limitation of the study. For example, crying, restlessness/ agitation, and playfulness of children led to loss of mothers’ concentration or devoting less time to do the interview. Cultural and ethnic variation and different accents (especially in relation to Afghan participants) made some semantic barriers and interfered with complete understanding of their responses, which was greatly resolved by frequent listening to the interview tape recordings and getting help from local personnel. CONCLUSION A part of health care officials’ success in immunization programs depends on controlling parents’ concerns over their child’s vaccination, which requires careful planning and regular monitoring and increasing of parents’ education by health care system personnel. Therefore, health care personnel have to be educated and prepared to deal with concerns, questions, or negative attitudes of parents towards their child’s vaccinations. In this regard, it is necessary to have a complete and correct perception of parents’ concerns, their communication problems, and ways of providing appropriate information about vaccination. The present study has provided essential data in these areas. ACKNOWLEDGMENT We gratefully acknowledge the parents who participated in interviews. DECLARATION OF INTEREST This study was approved and funded by the Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences (Grant No. 11497). REFERENCES Andre, F. E., Booy, R., Bock, H. L., Clemens, J., Datta, S. K., John, T. J., Lee, B. W., Lolekha, S., Peltola, H., Ruff, T. A., Santosham, M., Schmitt, H. J. (2008).
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