Family Practice Advance Access published May 22, 2015 Family Practice, 2015, 1–6 doi:10.1093/fampra/cmv035
Qualitative Research
Parental views on childhood vaccination against viral gastroenteritis—a qualitative interview study Downloaded from http://fampra.oxfordjournals.org/ at Georgetown University on May 27, 2015
Fiona V Lugga,b,*, Christopher C Butlera,c, Meirion R Evansa, Fiona Wooda and Nick A Francisa Institute of Primary Care & Public Health and bSouth East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK and cDepartment of Primary Care Health Sciences, University of Oxford, Oxford, UK. a
*Correspondence to Fiona V Lugg, South East Wales Trials Unit, School of Medicine, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff University, Cardiff CF14 4YS, UK; E-mail: [email protected]
Abstract Background. Gastroenteritis (GE) causes significant morbidity, especially in young children. A vaccine against rotavirus, a common cause of viral GE (vGE), was added to the childhood immunization schedule in the UK in July 2013 and further related vaccines are under development. Aim. To explore parents’ beliefs about vGE and their attitudes towards vaccinating. Design and setting. Qualitative interview study with parents of children who had recently experienced an episode of GE. Method. Twenty-eight semi-structured interviews were conducted over the phone with parents. Interviews were audio-recorded, transcribed and analysed using standard thematic approaches. Results. Parents varied in their perception of the threat posed by GE, and parents who did not perceive GE as serious were less enthusiastic about vaccines. Other parents were supportive of vaccines in general and considered benefits to their child, their family and the wider community. Many parents said that they lacked knowledge about efficacy and effectiveness of GE vaccines but their underlying belief about the seriousness of illness motivated their attitudes. Conclusion. Acceptability of GE vaccines to parents could be improved by providing more information on both the burden of illness and the impact of rotavirus vaccine in other comparable countries. Key words: Child, gastroenteritis, patient acceptance of health care, primary health care, qualitative research, rotavirus vaccines.
Introduction Gastroenteritis (GE) in children is a common and important condition worldwide. In the UK, norovirus is the leading cause of GE and rotavirus is the most frequent cause of severe diarrhoea in children younger than 5 years. Norovirus (25%) and rotavirus (19%) together account for over almost a half of all diagnosed GE cases in this age group (1). It has been estimated that by the age of 5 years, almost every child will experience rotavirus GE, 1 in 7 will consult a GP, 1 in 22 will attend Accident and Emergency and 1 in 45 will
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need hospitalization (2). There is also a substantial socio-economic burden associated with GE. In a study of the impact of rotavirus infection on family life, the mean number of working days lost by UK parents or carers was 7.5 days, additional childcare was often required, and parents reported high levels of stress (3). Although not associated with a high mortality in industrialized countries, viral gastroenteritis (vGE) results in a large burden on both National Health Service (NHS) and community resources. Every year, in England and Wales, an estimated 130 000 children
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Methods Design Data reported in this paper are part of a larger study in England and Wales using qualitative interviews with parents of children who had recently suffered from an episode of GE. Interviews were conducted between December 2012 and May 2013. The aim of the larger study was to explore how parents managed acute GE including prevention, diet, medication and when and where they might seek further help. Parents were provided with an information leaflet about the aims of the study, but it did not seek to inform them on the management of the illness. This study intended to explore and describe this topic area, no assumptions were held by the authors prior to data collection.
GP practices were recruited from across Wales to collect prospective data on paediatric patients presenting to their GP with GE and invited parents during the primary care consultation to take part. The mumsnet advertisement invited parents of children who had recently (within 3 months) had an episode of GE. All participants provided written informed consent to take part. Interviews were conducted over the telephone, lasted ~25 minutes, were audio-recorded and transcribed verbatim.
Interview protocol The interview aimed to investigate participants’ understanding, experience and beliefs about GE and its management. A semi-structured topic guide was developed in order to ensure key topics were covered in every interview, while also providing the necessary flexibility for new themes and topics to emerge. One theme that emerged early during the interviews was parents’ attitudes towards vaccinating against vGE, in particular the rotavirus programme and research around norovirus immunization. All subsequent interviews included this topic area (Table 1).
Analytical approach Coding was carried out alongside the interviews in order to determine data saturation (14). Thematic analysis was conducted (15), coding was deductive—guided by the pre-defined research questions as well as inductive (driven by the data). A coding framework was developed and validated by two independent researchers for accuracy and reliability of its application to the transcribed data. All interview transcripts were managed using nVivo (version 10).
Results Characteristics of respondents Twenty-eight parents were interviewed in total. Data collection continued with new participants until the research team considered that a point of data saturation had been reached as no new themes had emerged for four consecutive interviews. Nine of these parents were approached by their GP, invited to participate and their details forwarded to the research team. Nineteen individuals got in touch with the research team either through the study website or by e-mail to indicate their interest in participation. Twelve were from mumsnet and seven were snowballed from individuals who had participated. Respondents were aged between 26 and 40 years and were all female; 30% of these participants were not in paid employment. Within this population, 13 participants had consulted their GP about their child’s recent GE illness, of which 9 were recruited at this point and the remaining 4 were recruited subsequent to a consultation. Table 2 describes the participants and child’s characteristics. Following five interviews, the schedule was amended to include attitudes towards vaccine as an additional topic for discussion.
Participants Participants were eligible if their child had recently (within 3 months of recruitment date) experienced an acute episode of GE. Children were eligible if they were less than 5 years at the time of illness, no other eligibility criteria was applied. Parents were recruited by means of a convenience sample, either by GPs taking part in a wider study; from responding to an advertisement on parenting website mumsnet (www.mumsnet.com), or by the method of snowballing (13) from recruited participants (Fig. 1).
Attitudes towards vaccines All participants showed support for vaccines in general indicating that it is a ‘positive thing that they are being developed’ (P13) and that they are ‘a hundred percent worth it’ (P28). Thematic analysis revealed four themes that related to prevention by vaccination— perception of the seriousness of vGE; perceived benefits of a vGE vaccination programme; effectiveness and immunity and concerns regarding vaccination against vGE.
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will visit their GP with rotavirus GE, around 12 700 children will be admitted to hospital, and there will be three to four deaths (2,4). The annual cost to the NHS for rotavirus alone is estimated at £14.8 million (2), with a further £1 million per annum attributable to working days lost (5). In November 2012, the Department of Health announced that GlaxoSmithKline’s Rotarix vaccine would be introduced to the UK’s routine childhood immunization schedule in July 2013 (6). Rotarix is a live, attenuated vaccine given orally. All infants are offered two doses of vaccine at 2 and 3 months of age. Rotavirus vaccine is already routinely given in Australia, Canada and the USA. In the USA, rotavirus-related hospital admissions have been reduced by more than two-thirds since the vaccine was introduced (7). In the UK, it is estimated that the rotavirus vaccination programme will prevent 74 000 GP consultations per year and lead to annual savings of over £11M (8). There is currently no vaccine against norovirus, but a nasal vaccine is under development (9). Preliminary data indicate that uptake is as high as 88% in the UK for eligible children receiving both doses by 25 weeks; however, uptake in Wales is reported to be considerably lower (59.4%). The uptake target in the UK is 95%. There have been a number of studies investigating non-uptake of a variety of vaccines in an attempt to understand the reasons why parents may not wish to vaccinate their child (10). Following the rotavirus vaccine introduction in the USA, one study explored parents’ beliefs and attitudes towards vaccination. This was in light of a previous rotavirus vaccine, Rotashield, associated with increased risk of intussusception, and thus the study aimed to uncover any effects this had on parents in the USA (11). It is anticipated that there may be other issues more prominent for parents in the UK and, in order to effectively address parental concerns, we need to understand these issues (12). As far as we know, no other study has focussed on UK parents’ awareness and attitudes towards vaccination against vGE. We carried out a qualitative study with parents of children who had recently suffered from GE in order to provide insights into their attitudes and beliefs about this acute, self-limiting illness, and in particular their attitudes towards vaccines to prevent vGE.
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Table 1. Semi-structured interview guide: questions added in as vGE vaccine topic emerged • Whether the participant has heard about a vaccine for vGE ◦ Formally: from GP? ◦ Informally: on the news? • Thoughts on such a vaccine ◦ How important is it to them? • Hypothetical: Would they give this to their child? ◦ If Yes, Why ◦ If No, Why not?
Table 2. Participant and child characteristics Age of mother (years)
Duration of interview (minutes)
Children in household
Duration of child’s illness (days)
Age of child (years)
Mean Range
33 26–40
25 18–36
2 1–5
4 0.5–11
2.5 0.5–5
Frequency (%)
Gender of child Male 15 (54)
Female 13 (46)
Socio-economic status High Medium 9 (32) 10 (36)
Low 9 (32)
Perception of the seriousness of viral GE There was a wide variation in beliefs as to how serious vGE was for their child. Many participants compared these vGE vaccination programmes with other current vaccine programmes such as the measles, mumps and rubella (MMR) vaccine and did not believe vGE to be as serious, which in turn led them to believe that it was less necessary for their child to receive a vaccine against vGE. Don’t get me wrong, I’ve vaccinated my children for MMR and all those things, but they’re killers and they spread in a different way, but [not for] something like rotavirus and norovirus... There aren’t many people dying from it are there?...so then I don’t really think that there’s much point, when people can cope with it themselves (P12)
Consulted GP 13 (46)
This participant rhetorically asked how many children died in the UK from GE and used that as part of their rationale for not supporting such a vaccine. Other participants also considered their child’s GE illness as mild and relatively insignificant and therefore did not consider the illness burdensome enough to warrant a vaccine. When my kids have got them they have never got them particularly badly it’s just an inconvenience so I’m not sure I’d want to put a vaccine in them for a, not a serious reason ... I wouldn’t be too worried about a vaccine (P10)
In contrast, participants who considered the vGE vaccine programmes as important were also those who considered vGE to be a greater threat to their children. These individuals tended to take
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Figure 1. Summary flowchart of recruitment process with participant numbers in brackets. Recruitment was via three methods: parents identified by GPs consulting about their child’s GE illness, parents responding to an advertisement places on Mumsnet and Snowballing. Snowballing: Participants who took part in the interviews were asked to identify and invite other eligible parents to take part in the study. Any interested individuals contacted the research team by e-mail or via the study website
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4 a wider perspective on the impact of GE, such as considering the impact of the illness on the wider community such as other families with young children. Participants referred to other families who had recently been affected by GE and referred to the severity of symptoms or the number of individuals in the family who had symptoms to emphasize the impact. One participant considered their own experience of GE illness and the impact of the illness on them, as well as discussing the impact of GE on hospitals and other public services. This participant perceives the vaccine to reduce both the susceptibility of her child to GE as well as reducing the spread of the virus in the community.
Another participant compared a norovirus vaccine programme to the annual flu immunization (which she indicated that she does not support) and discussed the differences between these vaccine programmes and why she would consider a norovirus vaccine. I’ve said no to the flu vaccination because, for myself and for her, [um] because I just kind of felt that our natural immune system would kind of, y’know, do the job really [um] but Norovirus, I don’t know, I’d wanna look into it a bit more, I’d be interested in that ‘cause I know so many families that it’s really knocked for six [made very ill]. So, that would be a different, y’know, I’d consider that quite differently to the kind of flu jab really. (P09)
This participant is comparing the seriousness of influenza with vGE and perceives vGE to be more of a threat to their child and other families. This individual also indicates a belief that different vaccines work in different ways and that the flu jab may not be as effective as a vGE vaccine.
Perceived benefits of a vGE vaccination programme Many of the participants discussed how successful and important vGE vaccine programmes would be to their community. One parent discussed the current problem of vGE in the area and the positive effect it would have in the community if vGE was reduced. I think if they had a vaccine that treated [rotavirus or norovirus] then I would definitely, I think a lot of parents would welcome it without a doubt definitely because it is so common and I think this year has been pretty bad with the diarrhoea and vomiting virus. I mean, every parent I talk to, you know, it is going around the schools like crazy and I don’t think I have actually seen it so bad as I have seen it this year without a doubt, so I mean you know hearing of a vaccine that could prevent it or, you know, deal with it I would definitely be willing to you know give it a go once the testing has all been done you know, definitely because I think that would help a lot of parents out, you know without a doubt. (P24)
One participant talked at length about why they would opt for the vaccine with reference to their beliefs that the side efects are the same for all vaccines therefore no new adverse events would occur for vGE vaccine. This individual also discussed their dislike of GE and the misery it incurs. I would jump at the chance because I don’t believe vaccines are harmful in general...My children have already been vaccinated against other things so if they were going to be amongst the rare
These positive beliefs towards the benefits of vaccinating against viral GE are linked, in the most part, with their view on the seriousness of the illness. These beliefs could be used to encourage vaccine uptake.
Effectiveness and immunity Concerns regarding the effectiveness of the vaccine against vGE pathogens was a recurring concern within this theme. There were two areas of concern, both of which are underpinned by a belief that catching the virus would result in the same immunity as receiving a vaccine. Firstly, parents linked the experience of their children suffering from multiple GE episodes each year to a belief that the immunity is short-lived and only applies to that specific infection therefore a vaccine would present a similar short-lived immunity against only one strain of a virus. it’s my understanding that I think once you’ve caught a certain type of norovirus or rotavirus you won’t get it again anyway and [um] I just assumed that there’s so many different types that it wouldn’t, you wouldn’t catch the same one each time (P10)
The second concern described by the parents was the belief that natural immunity, developed after experiencing the illness, was somehow better than artificial immunity induced by a vaccine. Some participants returned to the seriousness of the illness to consider whether a vaccine was appropriate for vGE. I think I would always choose to vaccinate [um] yeah I think it’s a positive thing that they are being developed [um] though part of me does think you know that maybe your body with something like norovirus just does have to ride it out and [um] my little girl didn’t seem too affected by it (P13) I believe that rotavirus vaccine is already used in some of the countries, possibly in America? [um] I think, I think if they did bring it, if it, if it sounds pretty safe then I’d be happy to vaccinate my children but I know rotavirus is one of the ones where you tend to get it badly the first time and as you get further episodes of it, it tends to be milder and milder and by adult you’ve generally got some immunity (P11)
This second quote not only draws out a knowledge of the vaccine in implementation in the USA but also continues to consider whether a vaccine would be beneficial for an illness which is mild in adults. It is unclear whether this indicates a lack of perception of seriousness for the child or just an acceptance that children will get it anyway.
Concerns regarding vaccination against vGE There were many reasons given why mothers were unsupportive of the vaccine programme. One participant related this vaccine programme to the MMR media coverage in 1998 and how her experience of those events affected her current cautious attitude to vaccinations. I don’t know about getting the other vaccines, there would have to be quite a lot of, [um], literature or research available to me to, to have to make a decision like that, ‘cause it’s similar to when my eldest daughter, when she had, uh, MMR, I looked into all of
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I would be delighted if they brought out a vaccine for that, [um] purely because I feel like I spend most winters waiting for them to go down with it and it’s so, so contagious [um] I mean, I know they always end up with a lot of people in the hospital with it and in the nursing homes and they keep having outbreaks like on a cruise ship, all this sort of thing [um] and it’s so unpleasant to have and yeah, I’d be very happy if they brought out a vaccine, I’d be first in the queue. I hate getting D&V [diarrhoea and vomiting] (P11)
people who are sensitive to ingredients in vaccines I think that would’ve already [um], manifested itself...Therefore I think it’s not going to be harmful to give my children vaccines, [um], and the inconvenience and misery of rotavirus, it’s just horrible and if you could actually vaccinate against one of these rapidly evolving viruses…then yeah I’d do it. Definitely. (P18)
Parental views on childhood vaccination against viral gastroenteritis that and although at the time there was lots of furore about all the links with autism and things like that, but I looked into all that and as far as I was concerned it wasn’t, um, I didn’t see the link that they were trying to put out there. So, like, I decided that was fine for her but there would have to be a lot of, um, research and stuff before I would give them any other kind of vaccine (P23)
Another participant perceived GE as a minimal threat to her child as she believed that diarrhoea is a natural phenomenon and therefore does not want to upset their child by giving them, what they perceived as, an unnecessary injection.
The reference to danger could possibly refer to a severe infection (possibly bacterial GE) which could result in more serious symptoms. The comparison of this to ‘just’ diarrhoea and vomiting implies a perception of little threat. One individual listed all of her efficacy concerns and perceived risks associated with vaccinations. One of her beliefs was that vaccines create novel evolved viruses by forcing the virus to mutate. oohh: I think that if you vaccinate for anything, something new comes along doesn’t it, and by allowing them to have it, they build up their own, um immunities to it, but it strengthens their immunity. I think vaccinations can just get ridiculous and there’s always side effects to these things that you discover whenever in the future... something like rotavirus and Norovirus there’s always going to be another virus of some sort around the corner, and you vaccinate against one thing and it will develop into something else so no. ((laughs)) (P12)
Another view discussed by one participant was the belief that a vaccine was not the best approach in preventing vGE and holistic approaches may be more appropriate. I’m not that keen on things like adding further things to the body and I’m not all that keen on previous things he’s had to have as part of his check ups and things. But just the MMR and that kind of thing. I probably wouldn’t actually know. I wouldn’t unless it was life threatening things like meningitis. He had that, he had an injection for that but something which isn’t life threatening as such which I don’t believe that norovirus is. So probably no, I probably wouldn’t tend to go for something like that all. I’m more keen on trying to manage it holistically or without medication or perhaps other ways. (P27)
Conclusion Summary All parents indicated that they supported vaccines in principle; however, attitudes towards a vaccine specifically against vGE were variable. There were four participants who were clearly against a vGE vaccine, seven indicated a hypothetical intention to vaccinate and the remaining participants were generally supportive although raised concerns or counter arguments during their discussion. There are both positive and negative motivations that impact on parents’ decisions to vaccinate their child against vGE. Participants held differing views about how serious the threat of vGE can be to their child, and children generally, and the impact of this illness on
the community. Those who did not foresee a significant benefit from a vGE vaccine also considered GE not to be serious. In contrast, many of the participants who considered the illness to be very serious thought that vaccination would benefit themselves, their child and the wider community, in reducing the burden of the illness. Discussions about the effectiveness of a vaccine indicated a lack of appreciation of the extent of the positive impact of the introduction of rotavirus vaccine in the USA and other countries. Only participants who could perceive no benefit of a vaccine discussed other reasons (other than concerns regarding efficacy) to not support viral GE vaccines. Their reasons were linked with the belief that their child experiencing a GE episode was no more burdensome than them receiving the vaccine. Some believed the side effects of the vaccine were the same as the symptoms of vGE and therefore could not perceive an important distinction between the two.
Strengths and limitations We believe that this is the first qualitative study about parental beliefs and attitudes towards immunization for vGE conducted in the UK following the announcement of the rotavirus vaccine to UK childhood vaccination schedule. It is important to note that the vaccine had not been introduced at the time of interviews. Our respondents were selected following a recent GE episode and therefore all had first-hand experience of the illness therefore is not representative of all UK parents as the vaccine is targeted at children who have not yet experienced vGE. On one hand, the views in the study population are thus influenced by the recent GE episode and may be more negative towards the illness and show greater support for the vaccination. However, as the cause of GE for most participants was not known and in most cases was perceived as mild, this may not reflect a rotavirus GE episode (which can present with more severe symptoms) therefore could underestimate support of rotavirus vaccine as their experience of illness does not reflect that of a severe vGE episode. Double coding of transcripts by an independent qualitative expert and peer debriefing throughout data collection and analysis has enhanced the credibility and validity of this research.
Comparison with existing literature The health belief model was first used in relation to understanding the barriers to polio vaccination (16) and therefore provides a useful theoretical framework for understanding the results of this study. It suggests that the likelihood of participating in a health-promoting behaviour is influenced both by the perceived benefits and barriers of the behaviour (the safety and effectiveness of the vaccine in this study) as well as the perceived health threat (the severity of vGE) and cues to action (such as the behaviour of others and media campaigns). Previous research has highlighted similar beliefs about the threat of illness influencing vaccination uptake for seasonal and pandemic influenza (16). Poland identified a widespread belief that the perceived risk of influenza infection and its complications is low and that this translated into low motivation to be vaccinated (16). Influenza is similar to vGE in being an acute, common infection, and it is therefore not surprising that there are similarities in views expressed about influenza vaccine and rotavirus vaccine. One concern previously highlighted as an important issue to address is the perceived risks associated with childhood vaccines (12). Participants in our study also mentioned their concern
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I would definitely not give my son that. Only because I just think diarrhoea and stuff is just a natural part I just think it’s erm you know natural for everyone to have diarrhoea at some point. So I guess. and I really, really hate putting, you know, I hate giving him needles anyway. So I don’t think that I would. Unless he was obviously dangerous and then maybe I would, yeah. But not just for diarrhoea and vomiting, I don’t think. (P28)
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Implications for practice and research Public information is required to ensure the message is communicated to parents that the vaccine is effective and the risks associated with the vaccine are low. A key area would be to discuss the vaccine efficacy with examples from other countries in Europe and the USA where the vaccine has been in routine use and has significantly reduced rotavirus associated morbidity. Raising awareness about the potential implications of vGE in young children as well as its burden on the community and NHS could influence parents’ views on vaccinating against vGE. Many of the participants indicated that they would like more information on these aspects. A recent Cochrane systematic review found that there is no clear evidence for the best method of improving parent knowledge of vaccines (21). However, previous studies indicate that the public are more likely to accept vaccinations advised by trusted physicians (16) therefore GPs and family nurses are well placed to do this. Future research should aim to explore best methods for increasing vaccine acceptance for vGE to ensure vaccine programmes are beneficial to the whole community. This work did not explore whether parent’s views differed based on the delivery of vaccines (oral/subcutaneous/intradermal), this would be an interesting area to explore in future work.
Acknowledgements The authors would like to thank all the parents who participated in the study and the staff at participating General Practices who helped with the recruitment.
Declaration Funding: this research was funded by the Wales School of Primary Care Research along with the funded PhD studentship from the MRC and Cardiff University. Ethical approval: ethical approval was obtained from the North Wales Research Ethics Committee (Central and East) Proportionate Review SubCommittee (reference 11/WA/0262). Conflict of interest: there are no conflicts of interest.
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regarding the risks of the vaccines and made reference to links with autism—a reference to the controversy about the risks associated with the MMR vaccine (The ‘Wakefield controversy’). Recent studies have identified that parents have concerns about the addition of more vaccines to an already full immunization schedule. For this reason, there has been a decline in vaccine uptake in the Netherlands (17) and has been reported in another study in the USA (18) as being a strong motivator to not receive new additional vaccines. Although this was not discussed by the parents in this study, it is likely to be a concern for parents who are actually considering this addition to the schedule (rather than hypothetical as was the case in these interviews). Previous studies have also identified childhood vaccine uptake to be related to other social factors (education, social deprivation) (19) as well as situational factors (convenience of vaccination) (20). This may be because we explored hypothetical vaccine behaviour rather than investigating actual decisions about vaccinating children in a population of low vaccine uptake for a specific vaccine.
Qualitative Research
Parental views on childhood vaccination against viral gastroenteritis—a qualitative interview study Downloaded from http://fampra.oxfordjournals.org/ at Georgetown University on May 27, 2015
Fiona V Lugga,b,*, Christopher C Butlera,c, Meirion R Evansa, Fiona Wooda and Nick A Francisa Institute of Primary Care & Public Health and bSouth East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK and cDepartment of Primary Care Health Sciences, University of Oxford, Oxford, UK. a
*Correspondence to Fiona V Lugg, South East Wales Trials Unit, School of Medicine, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff University, Cardiff CF14 4YS, UK; E-mail: [email protected]
Abstract Background. Gastroenteritis (GE) causes significant morbidity, especially in young children. A vaccine against rotavirus, a common cause of viral GE (vGE), was added to the childhood immunization schedule in the UK in July 2013 and further related vaccines are under development. Aim. To explore parents’ beliefs about vGE and their attitudes towards vaccinating. Design and setting. Qualitative interview study with parents of children who had recently experienced an episode of GE. Method. Twenty-eight semi-structured interviews were conducted over the phone with parents. Interviews were audio-recorded, transcribed and analysed using standard thematic approaches. Results. Parents varied in their perception of the threat posed by GE, and parents who did not perceive GE as serious were less enthusiastic about vaccines. Other parents were supportive of vaccines in general and considered benefits to their child, their family and the wider community. Many parents said that they lacked knowledge about efficacy and effectiveness of GE vaccines but their underlying belief about the seriousness of illness motivated their attitudes. Conclusion. Acceptability of GE vaccines to parents could be improved by providing more information on both the burden of illness and the impact of rotavirus vaccine in other comparable countries. Key words: Child, gastroenteritis, patient acceptance of health care, primary health care, qualitative research, rotavirus vaccines.
Introduction Gastroenteritis (GE) in children is a common and important condition worldwide. In the UK, norovirus is the leading cause of GE and rotavirus is the most frequent cause of severe diarrhoea in children younger than 5 years. Norovirus (25%) and rotavirus (19%) together account for over almost a half of all diagnosed GE cases in this age group (1). It has been estimated that by the age of 5 years, almost every child will experience rotavirus GE, 1 in 7 will consult a GP, 1 in 22 will attend Accident and Emergency and 1 in 45 will
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need hospitalization (2). There is also a substantial socio-economic burden associated with GE. In a study of the impact of rotavirus infection on family life, the mean number of working days lost by UK parents or carers was 7.5 days, additional childcare was often required, and parents reported high levels of stress (3). Although not associated with a high mortality in industrialized countries, viral gastroenteritis (vGE) results in a large burden on both National Health Service (NHS) and community resources. Every year, in England and Wales, an estimated 130 000 children
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Methods Design Data reported in this paper are part of a larger study in England and Wales using qualitative interviews with parents of children who had recently suffered from an episode of GE. Interviews were conducted between December 2012 and May 2013. The aim of the larger study was to explore how parents managed acute GE including prevention, diet, medication and when and where they might seek further help. Parents were provided with an information leaflet about the aims of the study, but it did not seek to inform them on the management of the illness. This study intended to explore and describe this topic area, no assumptions were held by the authors prior to data collection.
GP practices were recruited from across Wales to collect prospective data on paediatric patients presenting to their GP with GE and invited parents during the primary care consultation to take part. The mumsnet advertisement invited parents of children who had recently (within 3 months) had an episode of GE. All participants provided written informed consent to take part. Interviews were conducted over the telephone, lasted ~25 minutes, were audio-recorded and transcribed verbatim.
Interview protocol The interview aimed to investigate participants’ understanding, experience and beliefs about GE and its management. A semi-structured topic guide was developed in order to ensure key topics were covered in every interview, while also providing the necessary flexibility for new themes and topics to emerge. One theme that emerged early during the interviews was parents’ attitudes towards vaccinating against vGE, in particular the rotavirus programme and research around norovirus immunization. All subsequent interviews included this topic area (Table 1).
Analytical approach Coding was carried out alongside the interviews in order to determine data saturation (14). Thematic analysis was conducted (15), coding was deductive—guided by the pre-defined research questions as well as inductive (driven by the data). A coding framework was developed and validated by two independent researchers for accuracy and reliability of its application to the transcribed data. All interview transcripts were managed using nVivo (version 10).
Results Characteristics of respondents Twenty-eight parents were interviewed in total. Data collection continued with new participants until the research team considered that a point of data saturation had been reached as no new themes had emerged for four consecutive interviews. Nine of these parents were approached by their GP, invited to participate and their details forwarded to the research team. Nineteen individuals got in touch with the research team either through the study website or by e-mail to indicate their interest in participation. Twelve were from mumsnet and seven were snowballed from individuals who had participated. Respondents were aged between 26 and 40 years and were all female; 30% of these participants were not in paid employment. Within this population, 13 participants had consulted their GP about their child’s recent GE illness, of which 9 were recruited at this point and the remaining 4 were recruited subsequent to a consultation. Table 2 describes the participants and child’s characteristics. Following five interviews, the schedule was amended to include attitudes towards vaccine as an additional topic for discussion.
Participants Participants were eligible if their child had recently (within 3 months of recruitment date) experienced an acute episode of GE. Children were eligible if they were less than 5 years at the time of illness, no other eligibility criteria was applied. Parents were recruited by means of a convenience sample, either by GPs taking part in a wider study; from responding to an advertisement on parenting website mumsnet (www.mumsnet.com), or by the method of snowballing (13) from recruited participants (Fig. 1).
Attitudes towards vaccines All participants showed support for vaccines in general indicating that it is a ‘positive thing that they are being developed’ (P13) and that they are ‘a hundred percent worth it’ (P28). Thematic analysis revealed four themes that related to prevention by vaccination— perception of the seriousness of vGE; perceived benefits of a vGE vaccination programme; effectiveness and immunity and concerns regarding vaccination against vGE.
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will visit their GP with rotavirus GE, around 12 700 children will be admitted to hospital, and there will be three to four deaths (2,4). The annual cost to the NHS for rotavirus alone is estimated at £14.8 million (2), with a further £1 million per annum attributable to working days lost (5). In November 2012, the Department of Health announced that GlaxoSmithKline’s Rotarix vaccine would be introduced to the UK’s routine childhood immunization schedule in July 2013 (6). Rotarix is a live, attenuated vaccine given orally. All infants are offered two doses of vaccine at 2 and 3 months of age. Rotavirus vaccine is already routinely given in Australia, Canada and the USA. In the USA, rotavirus-related hospital admissions have been reduced by more than two-thirds since the vaccine was introduced (7). In the UK, it is estimated that the rotavirus vaccination programme will prevent 74 000 GP consultations per year and lead to annual savings of over £11M (8). There is currently no vaccine against norovirus, but a nasal vaccine is under development (9). Preliminary data indicate that uptake is as high as 88% in the UK for eligible children receiving both doses by 25 weeks; however, uptake in Wales is reported to be considerably lower (59.4%). The uptake target in the UK is 95%. There have been a number of studies investigating non-uptake of a variety of vaccines in an attempt to understand the reasons why parents may not wish to vaccinate their child (10). Following the rotavirus vaccine introduction in the USA, one study explored parents’ beliefs and attitudes towards vaccination. This was in light of a previous rotavirus vaccine, Rotashield, associated with increased risk of intussusception, and thus the study aimed to uncover any effects this had on parents in the USA (11). It is anticipated that there may be other issues more prominent for parents in the UK and, in order to effectively address parental concerns, we need to understand these issues (12). As far as we know, no other study has focussed on UK parents’ awareness and attitudes towards vaccination against vGE. We carried out a qualitative study with parents of children who had recently suffered from GE in order to provide insights into their attitudes and beliefs about this acute, self-limiting illness, and in particular their attitudes towards vaccines to prevent vGE.
Parental views on childhood vaccination against viral gastroenteritis
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Table 1. Semi-structured interview guide: questions added in as vGE vaccine topic emerged • Whether the participant has heard about a vaccine for vGE ◦ Formally: from GP? ◦ Informally: on the news? • Thoughts on such a vaccine ◦ How important is it to them? • Hypothetical: Would they give this to their child? ◦ If Yes, Why ◦ If No, Why not?
Table 2. Participant and child characteristics Age of mother (years)
Duration of interview (minutes)
Children in household
Duration of child’s illness (days)
Age of child (years)
Mean Range
33 26–40
25 18–36
2 1–5
4 0.5–11
2.5 0.5–5
Frequency (%)
Gender of child Male 15 (54)
Female 13 (46)
Socio-economic status High Medium 9 (32) 10 (36)
Low 9 (32)
Perception of the seriousness of viral GE There was a wide variation in beliefs as to how serious vGE was for their child. Many participants compared these vGE vaccination programmes with other current vaccine programmes such as the measles, mumps and rubella (MMR) vaccine and did not believe vGE to be as serious, which in turn led them to believe that it was less necessary for their child to receive a vaccine against vGE. Don’t get me wrong, I’ve vaccinated my children for MMR and all those things, but they’re killers and they spread in a different way, but [not for] something like rotavirus and norovirus... There aren’t many people dying from it are there?...so then I don’t really think that there’s much point, when people can cope with it themselves (P12)
Consulted GP 13 (46)
This participant rhetorically asked how many children died in the UK from GE and used that as part of their rationale for not supporting such a vaccine. Other participants also considered their child’s GE illness as mild and relatively insignificant and therefore did not consider the illness burdensome enough to warrant a vaccine. When my kids have got them they have never got them particularly badly it’s just an inconvenience so I’m not sure I’d want to put a vaccine in them for a, not a serious reason ... I wouldn’t be too worried about a vaccine (P10)
In contrast, participants who considered the vGE vaccine programmes as important were also those who considered vGE to be a greater threat to their children. These individuals tended to take
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Figure 1. Summary flowchart of recruitment process with participant numbers in brackets. Recruitment was via three methods: parents identified by GPs consulting about their child’s GE illness, parents responding to an advertisement places on Mumsnet and Snowballing. Snowballing: Participants who took part in the interviews were asked to identify and invite other eligible parents to take part in the study. Any interested individuals contacted the research team by e-mail or via the study website
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4 a wider perspective on the impact of GE, such as considering the impact of the illness on the wider community such as other families with young children. Participants referred to other families who had recently been affected by GE and referred to the severity of symptoms or the number of individuals in the family who had symptoms to emphasize the impact. One participant considered their own experience of GE illness and the impact of the illness on them, as well as discussing the impact of GE on hospitals and other public services. This participant perceives the vaccine to reduce both the susceptibility of her child to GE as well as reducing the spread of the virus in the community.
Another participant compared a norovirus vaccine programme to the annual flu immunization (which she indicated that she does not support) and discussed the differences between these vaccine programmes and why she would consider a norovirus vaccine. I’ve said no to the flu vaccination because, for myself and for her, [um] because I just kind of felt that our natural immune system would kind of, y’know, do the job really [um] but Norovirus, I don’t know, I’d wanna look into it a bit more, I’d be interested in that ‘cause I know so many families that it’s really knocked for six [made very ill]. So, that would be a different, y’know, I’d consider that quite differently to the kind of flu jab really. (P09)
This participant is comparing the seriousness of influenza with vGE and perceives vGE to be more of a threat to their child and other families. This individual also indicates a belief that different vaccines work in different ways and that the flu jab may not be as effective as a vGE vaccine.
Perceived benefits of a vGE vaccination programme Many of the participants discussed how successful and important vGE vaccine programmes would be to their community. One parent discussed the current problem of vGE in the area and the positive effect it would have in the community if vGE was reduced. I think if they had a vaccine that treated [rotavirus or norovirus] then I would definitely, I think a lot of parents would welcome it without a doubt definitely because it is so common and I think this year has been pretty bad with the diarrhoea and vomiting virus. I mean, every parent I talk to, you know, it is going around the schools like crazy and I don’t think I have actually seen it so bad as I have seen it this year without a doubt, so I mean you know hearing of a vaccine that could prevent it or, you know, deal with it I would definitely be willing to you know give it a go once the testing has all been done you know, definitely because I think that would help a lot of parents out, you know without a doubt. (P24)
One participant talked at length about why they would opt for the vaccine with reference to their beliefs that the side efects are the same for all vaccines therefore no new adverse events would occur for vGE vaccine. This individual also discussed their dislike of GE and the misery it incurs. I would jump at the chance because I don’t believe vaccines are harmful in general...My children have already been vaccinated against other things so if they were going to be amongst the rare
These positive beliefs towards the benefits of vaccinating against viral GE are linked, in the most part, with their view on the seriousness of the illness. These beliefs could be used to encourage vaccine uptake.
Effectiveness and immunity Concerns regarding the effectiveness of the vaccine against vGE pathogens was a recurring concern within this theme. There were two areas of concern, both of which are underpinned by a belief that catching the virus would result in the same immunity as receiving a vaccine. Firstly, parents linked the experience of their children suffering from multiple GE episodes each year to a belief that the immunity is short-lived and only applies to that specific infection therefore a vaccine would present a similar short-lived immunity against only one strain of a virus. it’s my understanding that I think once you’ve caught a certain type of norovirus or rotavirus you won’t get it again anyway and [um] I just assumed that there’s so many different types that it wouldn’t, you wouldn’t catch the same one each time (P10)
The second concern described by the parents was the belief that natural immunity, developed after experiencing the illness, was somehow better than artificial immunity induced by a vaccine. Some participants returned to the seriousness of the illness to consider whether a vaccine was appropriate for vGE. I think I would always choose to vaccinate [um] yeah I think it’s a positive thing that they are being developed [um] though part of me does think you know that maybe your body with something like norovirus just does have to ride it out and [um] my little girl didn’t seem too affected by it (P13) I believe that rotavirus vaccine is already used in some of the countries, possibly in America? [um] I think, I think if they did bring it, if it, if it sounds pretty safe then I’d be happy to vaccinate my children but I know rotavirus is one of the ones where you tend to get it badly the first time and as you get further episodes of it, it tends to be milder and milder and by adult you’ve generally got some immunity (P11)
This second quote not only draws out a knowledge of the vaccine in implementation in the USA but also continues to consider whether a vaccine would be beneficial for an illness which is mild in adults. It is unclear whether this indicates a lack of perception of seriousness for the child or just an acceptance that children will get it anyway.
Concerns regarding vaccination against vGE There were many reasons given why mothers were unsupportive of the vaccine programme. One participant related this vaccine programme to the MMR media coverage in 1998 and how her experience of those events affected her current cautious attitude to vaccinations. I don’t know about getting the other vaccines, there would have to be quite a lot of, [um], literature or research available to me to, to have to make a decision like that, ‘cause it’s similar to when my eldest daughter, when she had, uh, MMR, I looked into all of
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I would be delighted if they brought out a vaccine for that, [um] purely because I feel like I spend most winters waiting for them to go down with it and it’s so, so contagious [um] I mean, I know they always end up with a lot of people in the hospital with it and in the nursing homes and they keep having outbreaks like on a cruise ship, all this sort of thing [um] and it’s so unpleasant to have and yeah, I’d be very happy if they brought out a vaccine, I’d be first in the queue. I hate getting D&V [diarrhoea and vomiting] (P11)
people who are sensitive to ingredients in vaccines I think that would’ve already [um], manifested itself...Therefore I think it’s not going to be harmful to give my children vaccines, [um], and the inconvenience and misery of rotavirus, it’s just horrible and if you could actually vaccinate against one of these rapidly evolving viruses…then yeah I’d do it. Definitely. (P18)
Parental views on childhood vaccination against viral gastroenteritis that and although at the time there was lots of furore about all the links with autism and things like that, but I looked into all that and as far as I was concerned it wasn’t, um, I didn’t see the link that they were trying to put out there. So, like, I decided that was fine for her but there would have to be a lot of, um, research and stuff before I would give them any other kind of vaccine (P23)
Another participant perceived GE as a minimal threat to her child as she believed that diarrhoea is a natural phenomenon and therefore does not want to upset their child by giving them, what they perceived as, an unnecessary injection.
The reference to danger could possibly refer to a severe infection (possibly bacterial GE) which could result in more serious symptoms. The comparison of this to ‘just’ diarrhoea and vomiting implies a perception of little threat. One individual listed all of her efficacy concerns and perceived risks associated with vaccinations. One of her beliefs was that vaccines create novel evolved viruses by forcing the virus to mutate. oohh: I think that if you vaccinate for anything, something new comes along doesn’t it, and by allowing them to have it, they build up their own, um immunities to it, but it strengthens their immunity. I think vaccinations can just get ridiculous and there’s always side effects to these things that you discover whenever in the future... something like rotavirus and Norovirus there’s always going to be another virus of some sort around the corner, and you vaccinate against one thing and it will develop into something else so no. ((laughs)) (P12)
Another view discussed by one participant was the belief that a vaccine was not the best approach in preventing vGE and holistic approaches may be more appropriate. I’m not that keen on things like adding further things to the body and I’m not all that keen on previous things he’s had to have as part of his check ups and things. But just the MMR and that kind of thing. I probably wouldn’t actually know. I wouldn’t unless it was life threatening things like meningitis. He had that, he had an injection for that but something which isn’t life threatening as such which I don’t believe that norovirus is. So probably no, I probably wouldn’t tend to go for something like that all. I’m more keen on trying to manage it holistically or without medication or perhaps other ways. (P27)
Conclusion Summary All parents indicated that they supported vaccines in principle; however, attitudes towards a vaccine specifically against vGE were variable. There were four participants who were clearly against a vGE vaccine, seven indicated a hypothetical intention to vaccinate and the remaining participants were generally supportive although raised concerns or counter arguments during their discussion. There are both positive and negative motivations that impact on parents’ decisions to vaccinate their child against vGE. Participants held differing views about how serious the threat of vGE can be to their child, and children generally, and the impact of this illness on
the community. Those who did not foresee a significant benefit from a vGE vaccine also considered GE not to be serious. In contrast, many of the participants who considered the illness to be very serious thought that vaccination would benefit themselves, their child and the wider community, in reducing the burden of the illness. Discussions about the effectiveness of a vaccine indicated a lack of appreciation of the extent of the positive impact of the introduction of rotavirus vaccine in the USA and other countries. Only participants who could perceive no benefit of a vaccine discussed other reasons (other than concerns regarding efficacy) to not support viral GE vaccines. Their reasons were linked with the belief that their child experiencing a GE episode was no more burdensome than them receiving the vaccine. Some believed the side effects of the vaccine were the same as the symptoms of vGE and therefore could not perceive an important distinction between the two.
Strengths and limitations We believe that this is the first qualitative study about parental beliefs and attitudes towards immunization for vGE conducted in the UK following the announcement of the rotavirus vaccine to UK childhood vaccination schedule. It is important to note that the vaccine had not been introduced at the time of interviews. Our respondents were selected following a recent GE episode and therefore all had first-hand experience of the illness therefore is not representative of all UK parents as the vaccine is targeted at children who have not yet experienced vGE. On one hand, the views in the study population are thus influenced by the recent GE episode and may be more negative towards the illness and show greater support for the vaccination. However, as the cause of GE for most participants was not known and in most cases was perceived as mild, this may not reflect a rotavirus GE episode (which can present with more severe symptoms) therefore could underestimate support of rotavirus vaccine as their experience of illness does not reflect that of a severe vGE episode. Double coding of transcripts by an independent qualitative expert and peer debriefing throughout data collection and analysis has enhanced the credibility and validity of this research.
Comparison with existing literature The health belief model was first used in relation to understanding the barriers to polio vaccination (16) and therefore provides a useful theoretical framework for understanding the results of this study. It suggests that the likelihood of participating in a health-promoting behaviour is influenced both by the perceived benefits and barriers of the behaviour (the safety and effectiveness of the vaccine in this study) as well as the perceived health threat (the severity of vGE) and cues to action (such as the behaviour of others and media campaigns). Previous research has highlighted similar beliefs about the threat of illness influencing vaccination uptake for seasonal and pandemic influenza (16). Poland identified a widespread belief that the perceived risk of influenza infection and its complications is low and that this translated into low motivation to be vaccinated (16). Influenza is similar to vGE in being an acute, common infection, and it is therefore not surprising that there are similarities in views expressed about influenza vaccine and rotavirus vaccine. One concern previously highlighted as an important issue to address is the perceived risks associated with childhood vaccines (12). Participants in our study also mentioned their concern
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I would definitely not give my son that. Only because I just think diarrhoea and stuff is just a natural part I just think it’s erm you know natural for everyone to have diarrhoea at some point. So I guess. and I really, really hate putting, you know, I hate giving him needles anyway. So I don’t think that I would. Unless he was obviously dangerous and then maybe I would, yeah. But not just for diarrhoea and vomiting, I don’t think. (P28)
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Implications for practice and research Public information is required to ensure the message is communicated to parents that the vaccine is effective and the risks associated with the vaccine are low. A key area would be to discuss the vaccine efficacy with examples from other countries in Europe and the USA where the vaccine has been in routine use and has significantly reduced rotavirus associated morbidity. Raising awareness about the potential implications of vGE in young children as well as its burden on the community and NHS could influence parents’ views on vaccinating against vGE. Many of the participants indicated that they would like more information on these aspects. A recent Cochrane systematic review found that there is no clear evidence for the best method of improving parent knowledge of vaccines (21). However, previous studies indicate that the public are more likely to accept vaccinations advised by trusted physicians (16) therefore GPs and family nurses are well placed to do this. Future research should aim to explore best methods for increasing vaccine acceptance for vGE to ensure vaccine programmes are beneficial to the whole community. This work did not explore whether parent’s views differed based on the delivery of vaccines (oral/subcutaneous/intradermal), this would be an interesting area to explore in future work.
Acknowledgements The authors would like to thank all the parents who participated in the study and the staff at participating General Practices who helped with the recruitment.
Declaration Funding: this research was funded by the Wales School of Primary Care Research along with the funded PhD studentship from the MRC and Cardiff University. Ethical approval: ethical approval was obtained from the North Wales Research Ethics Committee (Central and East) Proportionate Review SubCommittee (reference 11/WA/0262). Conflict of interest: there are no conflicts of interest.
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regarding the risks of the vaccines and made reference to links with autism—a reference to the controversy about the risks associated with the MMR vaccine (The ‘Wakefield controversy’). Recent studies have identified that parents have concerns about the addition of more vaccines to an already full immunization schedule. For this reason, there has been a decline in vaccine uptake in the Netherlands (17) and has been reported in another study in the USA (18) as being a strong motivator to not receive new additional vaccines. Although this was not discussed by the parents in this study, it is likely to be a concern for parents who are actually considering this addition to the schedule (rather than hypothetical as was the case in these interviews). Previous studies have also identified childhood vaccine uptake to be related to other social factors (education, social deprivation) (19) as well as situational factors (convenience of vaccination) (20). This may be because we explored hypothetical vaccine behaviour rather than investigating actual decisions about vaccinating children in a population of low vaccine uptake for a specific vaccine.
