Abstract
In 2014, Stockholm became the first Swedish county to introduce the rotavirus vaccine, which is given from as early as six weeks of age. The aim of this study was to describe parental conceptions of rotavirus infection and vaccination during its implementation as part of the child immunization program, as their support is vital for any new vaccine. The study followed a descriptive, qualitative design with a phenomenographic approach. Ten in-depth interviews with parents were conducted in Stockholm County, transcribed and analyzed to describe qualitatively different conceptions of rotavirus infection and vaccination. Four main categories were identified: to vaccinate without doubt, hesitant to vaccinate, risky to vaccinate, and unnecessary to vaccinate. All the parents had in common the desire to protect their children from suffering, either by vaccinating their child in order to avoid rotavirus infection or by not vaccinating their child because of concerns about the side effects. It is important that child health-care professionals understand the variations of conceptions that influence the parents’ decisions and that these conceptions may differ considerably. Individualized parental information about rotavirus infection and vaccination would help to achieve a successful implementation of the vaccination program.
Introduction
Rotavirus is a contagious, common cause of childhood gastroenteritis and its symptoms include vomiting, diarrhea, and fever. Most children are affected before the age of five and the youngest children are at risk of severe dehydration requiring hospitalization and fluid therapy (Grimwood et al., 2010; Tate et al., 2012). Worldwide, rotavirus is a great cause of child mortality (Lanata et al., 2013; Tate et al., 2012) but in high-income countries such as Sweden, deaths are rare, although morbidity is considerable (Rinder et al., 2014). Rotavirus infections cause suffering for both children and their families and are a burden on health-care resources. About 2500 children were hospitalized due to rotavirus infection yearly in Sweden, whereof about 500 children in Stockholm, before the introduction of the rotavirus vaccine (Rinder et al., 2014).
The World Health Organization has recommended all countries to introduce the rotavirus vaccine in their national immunization programs (Gothefors et al., 2008; WHO position paper, 2013) and 81 countries had done so by spring 2016. In 2014, Stockholm became the first Swedish county to offer the vaccine to all newborn children, and recently the Swedish Public Health Agency has recommended that rotavirus vaccination should be included in the national immunization program (Swedish Public Health Agency, 2017). All vaccinations in Sweden are completely voluntary. Two years after the implementation of the vaccine in Stockholm, a coverage of 85% has been reached, according to statistics provided by the county (Child Health Stockholm County, 2017).
RotaTeq® (MSD, Merck & Co., Inc., Kenilworth, New Jersey, USA) was used during the study period. Unlike other vaccines in the Swedish National Vaccine Program, the rotavirus vaccine is administered orally, with the first dose between 6 and 12 weeks of age. The rotavirus vaccine has been shown generally to be a well-tolerated vaccine with high efficacy worldwide (Soares-Weiser et al., 2012). Intussusception is a severe, but rare, side effect of rotavirus vaccines (Benin et al., 2006; Buttery et al., 2011; Soares-Weiser et al., 2012) and all doses should be administered before the age of six months in order to avoid the period when the incidence of intussusception is the highest, at five to nine months of age (Kuppermann et al., 2000).
To achieve a successful implementation of the rotavirus vaccination program, it is important to study parental knowledge, attitudes, and opinions of rotavirus infection and vaccine (Benin et al., 2006; Kelley et al., 2015; Patel et al., 2007; Smith et al., 2011). There are studies worldwide of parental attitudes toward vaccines but no qualitative study of parental conceptions of the rotavirus vaccine has been performed in Sweden. It is of particular interest to study the implementation of this vaccine in countries such as Sweden since this vaccine, in contrast to other vaccines included in the national immunization program, targets a disease with nonexistent mortality. The aim of this study was to study parental conceptions of rotavirus infection and vaccination using the Consolidated Framework for Implementation Research (CFIR), a model based on previous research on implementation in health care (Damschroder et al., 2009). CFIR was established by a group of researchers to promote a framework for future research and highlight the importance of identifying and expressing the needs of care recipients to increase the chances of successful implementation of new vaccination programs.
Material and methods
Study design
We used a descriptive design and a phenomenographic approach (Sjöström and Dahlgren, 2002). In-depth interviews were conducted with open questions to study the variety of ways that parents understand and conceive the rotavirus infection and its vaccine. The interviews were transcribed and analyzed by the researchers using a phenomenographic analysis.
Sampling and study setting
In spring 2014, parents from five child health care centers in different socioeconomic areas in the center of Stockholm County were selected for the study, by one nurse at each center. The inclusion criteria were to select parents with different backgrounds to get variations of experiences and that the parents could speak Swedish. The participants were all parents of children aged four to six weeks, born after March 11, 2014, who had been offered, but not yet received, the first dose of the rotavirus vaccine. The nurses gave oral and written information about the study and informed that participation was voluntary. Both parents were invited to the interviews and left to decide by themselves whether one or both would participate. The parents contacted the first author if they wanted to take part in the study. Ten participants were chosen for the interviews. Nine of the participants were mothers and one father attended along with his partner. For three parents, it was their firstborn child. Seven parents had two or more children. The parents’ ages varied from 27 to 38 years, (median age 32). Although the participants were chosen from different socioeconomic areas in Stockholm, they had similar sociodemographic backgrounds.
Data collection
A pilot interview was conducted to test and evaluate the interview guide (Table 1). This comprised questions on the parents’ knowledge, experiences, and conceptions of rotavirus infection and vaccination.
Guide for interviews with parents about rotavirus vaccination.
After the pilot interview, 10 interviews were conducted, 7 in the parents’ home and 3 at a child health center. The in-depth interviews lasted between 30 and 60 minutes to obtain a clear understanding of the participants’ view about the topic. The interviews were recorded and transcribed verbatim into text by the first author.
Data analysis
In accordance with the phenomenography design, we studied and systematized participants’ various thoughts about rotavirus vaccination into qualitatively different conceptions (Marton, 1981; Sjöström and Dahlgren, 2002). The first author began the analysis by reading all the data to be familiar with the interview text. The next step was to identify and condense the meaning units that describe how the participants understood the phenomenon. A preliminary grouping of the meaning units, based on similarities and differences, was performed, followed by analyzing the categories to evolve the parents’ underlying and qualitatively different conceptions of rotavirus infection and vaccination. Four main descriptive categories were identified to describe the underlying conceptions. The categories of description were hierarchically ordered into “what” and “how” aspects (Marton and Booth, 1997) and illustrated by selected quotations, numbered with the interviews 1–10.
Ethical considerations
The regional ethical review board in Stockholm approved the study (2013/2041-31) and the parents provided verbal informed consent in line with the Declaration of Helsinki (Association TWM, 2013).
Results
Four main descriptive categories of parental conceptions of rotavirus infection and vaccination were identified: without doubt, hesitancy, risky, and unnecessary. Each main category had subcategories that originated from various, and equally worthy, conceptions (Figure 1).
Sample space of the four main categories and the underlying categories of parental perceptions of the rotavirus vaccine.
To vaccinate without doubt
One main conception of the rotavirus vaccination was to vaccinate the child without any doubt and the descriptive category had three subcategories.
Confidence in what the health-care professionals say
Some parents had great confidence in the child health center unit and the child health center nurse. They believed they had received enough information about the vaccine and had no need to search for further information. Some participants relied on vaccines in general and had let their older children be vaccinated with vaccines that were not included in the national immunization program. Some said that they had been recommended the rotavirus vaccination and therefore believed in it. A number of parents had been directed to Internet links so that they could learn more about the rotavirus vaccine, but had actively avoided reading Internet sites because they believed that such information could be confusing. One parent said they had received adequate information from the child health center and decided not to search the Internet, stating “I can find it difficult to assess the things that are on the Internet and so I do not know more than what is in the brochure” (interview 1).
Parents were confident about accepting the offer of the rotavirus vaccine as it came from the child health center, which always had the child’s best interests in mind. Although some parents had not heard of rotavirus infection before, they were convinced that they should vaccinate their child against it, saying that they generally trusted Swedish health-care professionals based on previous experiences. They believed that the health-care professionals would have more knowledge, than themselves, and were confident with their recommendations.
Protection against disease and suffering
Some participants perceived a need to protect their children against diseases and suffering. They described rotavirus infection as gastroenteritis with a prolonged and more difficult course than other viruses, both for the child and the whole family. They worried that their newborn baby could contract the infection from their older siblings who were in day care. One parent said: “Last year everyone in the family had stomach flu at the same time…My child became sick first, my husband two days later, then me just two hours after him. Grandma had to assist and cook for our child” (interview 2).
Participants also expressed concerns that it could be difficult to provide fluid to a small child and that younger children were more at risk of dehydration and hospitalization. They were grateful that they could prevent the rotavirus by having their child vaccinated. Some pointed out that rotavirus infections could be fatal.
Leave the decision to health-care professionals
Some parents had positive experiences of previous vaccinations and felt there was no reason to refuse the vaccine. A number of parents felt the vaccine must have been well studied before its introduction and believed in vaccinations in general. Vaccination was never discussed by the family. These parents left vaccination decisions to health-care professionals and were determined to complete the full vaccination program. As one parent said: “We have not had that kind of discussion at home, if vaccination is right or wrong” (interview 1).
Hesitancy to vaccinate
Some participants were ambivalent or reluctant to vaccinate their children and two underlying categories described this descriptive category of hesitancy.
May cause side effects
Concerns about possible side effects were expressed. Parents had a responsibility to protect their children against disease and suffering, which led to ambivalence about giving their child the rotavirus vaccine. They felt that it would be worse if the child got an intussusception as a side effect of the vaccine rather than a serious rotavirus infection. As one parent said: “It is about what is worst for my child…what if she got the infection versus the worst side effect of the vaccine” (interview 3).
These parents asked whether the rotavirus vaccine had been properly studied and tested and whether there could be future unknown side effects. Narcolepsy due to the pandemic influenza vaccine in 2009 was mentioned in this context. There were concerns that the pandemic vaccine had also been recommended by health-care professionals and that unknown side effects appeared afterward. This affected the parents’ views of other vaccines, like the rotavirus vaccine.
Want to make their own decisions
Some parents wanted to search for information themselves and decide which vaccines they would give their children. They wanted to use other sources of information and discuss the matter with family and friends before deciding. Decision-making was also affected by the side effects of the pandemic influenza vaccine. Some parents first heard about the rotavirus when they were offered the vaccine against it. This was at the first meeting with child health care, often a home visit by the child health center nurse, and the vaccination details were accompanied by lots of other information. This information overload was deemed stressful by the parents. Also, the short time period between receiving the information and having to decide was perceived as stressful. One parent explained that it was hard to make decisions when they received so much information, saying: “It is a bit difficult to sort the information” (interview 4). These parents listened to their inner compass and made their own decisions after collecting information from scattered sources, including child health care and the Internet.
Risky to vaccinate
The third main descriptive category, with two subcategories, described parents’ conceptions that the rotavirus vaccination could risk the child’s long-term health.
The child is too small to be vaccinated
Because the first dose had to be given as early as between 6 and 12 weeks of age, some parents considered the child too young to be vaccinated. They even believed that it was too early to start the general national vaccination program at three months and that this would only be necessary if the family was travelling abroad. One parent said: “I think they should be somewhat older…One-year old perhaps. Not tiny, tiny babies…I think they should be vaccinated if travelling though” (interview 6).
These parents believed there were few severe diseases in Sweden and that there was no need to vaccinate children so early. They also felt uncomfortable with vaccines in the child’s body if they did not know they were necessary.
Vaccines can affect the immune system
Some were concerned that the rotavirus vaccination could affect the child’s immune system, that the rotavirus was not a sufficiently serious illness, and that it was important that the child built up its own immune system the natural way. Therefore, they argued vaccination against the rotavirus was not necessary. Participants said that gathering information about the vaccine and immune system was time consuming and, therefore, they were not vaccinating.
As one parent said: “Isn't it good to have some immune resistance?…Now I have to Google a bit about immune system and stuff” (interview 5).
Unnecessary to vaccinate
The fourth main descriptive category was that it was unnecessary to vaccinate children and this was divided into three subcategories.
Confidence in good health care
Some parents had an older child who had been hospitalized for a rotavirus infection and had received good health care. That positive outcome and experience made those parents think that it was unnecessary to vaccinate their newborn baby. As one said: “Yes, the doctor and the nurses took care of us. It went well” (interview 5). The perception that the sibling did not suffer, despite hospitalization, gave the parents a feeling of calmness and they were not worried. They stressed that Swedish health care is good and children don’t die of rotavirus infections in Sweden.
Believe in the child’s own strength
Some parents believed in their child’s own strength that they would cope with a possible rotavirus infection and only be sick for a few days without the risk of any complications. Parents also said they themselves were strong and rarely sick. As one parent said: She is pretty robust and I believe she is a larger child than others…thereby perhaps also more durable for her age…if we had a more fragile child perhaps we would do more to try to avoid every little virus she could be infected with…Maybe it is wrong, but we think like this. (interview 3)
The parents who said it was unnecessary to vaccinate still felt it was good that the vaccine was available free of charge, because other children might need to be vaccinated. They were also grateful that they receive social insurance to care for their children when they become ill and thought that the worst-case scenario would be a week off from work and maybe a doctor’s consultation for their child. Some said that families should try to avoid seeking medical care when their child was affected by gastroenteritis, because of the risk of infecting other children.
Rotavirus is considered harmless
Some parents felt the rotavirus was not a life-threatening infection in Sweden and it was unnecessary to vaccinate children against it. One of the participants found it difficult to believe the information from child health care that it was a severe form of gastroenteritis and they thought that the duration would be more limited.
Others felt that the vaccine was unnecessary because they could take care of an infected child and referred to earlier periods of infections in the family. One parent shared their own experience: “It was hard, but then you know somehow it will end, it will pass…It’s really mostly rest and fluid that helps” (interview 6).
These parents knew there were other viruses that could cause gastroenteritis and the fact that their child could have gastroenteritis despite the vaccination made them think that vaccination against rotavirus infection was unnecessary.
Discussion
The results from this study were that the parents’ conceptions of rotavirus infection and vaccination fell into four main categories of description: without doubt, hesitancy, risky, and unnecessary. The results can supply health-care professionals with knowledge about variations about how parents understand and conceive the rotavirus vaccination and what conceptions are behind the parents’ decisions to agree or disagree to the vaccination.
In our study, one conception was to vaccinate the child without doubt as protection against disease and suffering. This is in accordance with previous research (Kelley et al., 2015) where highly rated vaccine safety was found to be a significant predictor of parents’ intention to vaccinate their children. To vaccinate without doubt implies also that parents trusted health-care professionals’ recommendations. This can be compared with previous studies on parental attitudes toward children’s vaccinations where a good relationship with health-care workers promotes vaccinations (Benin et al., 2006; Brown et al., 2010; Leask et al., 2012; Patel et al., 2007; Schollin Ask et al., 2017). However, our results also show that although parents perceive good relationships with health-care professionals and confidence in health care, they can conceive that the rotavirus vaccination is unnecessary and the disease is not harmful. Previous research confirms this conception as a reason given by parents who refuse vaccination (Fredrickson et al., 2004; Freed et al., 2010; Gust et al., 2008).
Within the main category hesitancy, parents were concerned about the side effects of the vaccine. This is in accordance with a previous study (Kelley et al., 2015) where safety concerns and too many vaccinations administered at one time was the most common reason for not vaccinating. The same hesitant group of parents, in our study, used additional information sources rather than health-care professionals, and this has been described earlier as being common within hesitant parents who needed more information to be able to decide about vaccinating their child (Ames et al., 2017; Kelley et al., 2015).
The conception risky to vaccinate showed that some parents in the present study refused vaccination because they feared the child was too young and that vaccination could negatively affect the child’s future health. The timing of the rotavirus vaccination, with the first dose already between 6 and 12 weeks, is based on the risk of intussusception which increases as the child gets older (Benin et al., 2006; Buttery et al., 2011; Soares-Weiser et al., 2012). The rotavirus vaccine may not be delayed, as other vaccines can. A previous study also showed that parents thought their child was too young to receive a live rotavirus vaccine (Smith et al., 2011). Several parents shared the view that vaccinations could influence the immune system, even though they were not aware of the mechanism for this. Accordingly, it is important that health-care professionals inform the parents about the time aspect of vaccination and the immune system.
The conception unnecessary to vaccinate groups implied that rotavirus infection was not severe enough to vaccinate against, some had experience of siblings affected by rotavirus infection and had managed it well. This is in line with other studies, not believing the targeted infection being serious enough or having the perception of a lower risk of being infected. (Bennett and Smith, 1992; Bond et al., 1998; Brown et al., 2010; Shawn and Gold, 1987). One result in our study that differs from others was the subcategory unnecessary group that had concerns about themselves spreading the disease when not being vaccinated, showing an awareness of social responsibility which is not common among vaccine hesitancy groups (Williams, 2014).
Parents’ decision of vaccinating is a multifactorial and complex process (Benin et al., 2006; Downs et al., 2008; Leask et al., 2012; MacDonald, 2015). It is not as simple as being pro or against vaccinating. Studies have also shown that parents who refuse vaccine tend to cluster geographically, possibly due to shared cultural beliefs (Omer et al., 2009; Smith et al., 2011; Wenger et. al., 2011).
This knowledge emphasizes the importance of the sensitivity of health-care professionals when they communicate with parents about vaccination (Leask et al., 2012). A recent Cochrane review (Ames et al., 2017) summarized the needs of communicating about vaccines and presented the importance of the timing of information, of having balanced and tailored information to parents’ needs and also having more information within hesitant groups of parents to keep trust in vaccines high as well as addressing common sources of misinformation. Professional expertise in partnership with parents can support and change their attitude and way of thinking. The partnership implies that health-care professionals can use their expertise to understand the family’s situation and recognize the parents as experts in their lives. This involves questioning and listening to responses and creating possibilities for new understanding (Clerke et al., 2017).
Strengths and limitations
To our knowledge, this is the first Swedish qualitative study about parental perceptions of the implementation of the rotavirus vaccination program. The results could be a helpful tool in the communication between health-care professionals and parents about the rotavirus vaccination and other new vaccines with the aim of maintaining the general trust in vaccines in Sweden, with high vaccine coverage in general. In Sweden, the child health center nurse is the parents’ principal source of information of the rotavirus vaccine.
The study has limitations and these are concerned with the selection of the participants. First, only one father participated in the interviews. It would have been interesting to see how, and whether, the results would have been affected if more fathers had participated. Previous studies have shown the differences in attitudes and concerns about vaccinations between men and women (Freed et al., 2010). Gust et al. (2005) presented results of fathers being more skeptical about vaccines than mothers in their survey.
A second limitation is that there may be a selection bias or a participation bias. The responders presented with a similar demographic background and it could be the case that parents with particular interests in vaccine were the ones that participated in the study, thus affecting the results.
Third, the interviews did not contain any sociodemographic markers or issues. This is a limitation. For example, it has been shown, according to statistics of Stockholm County, that the rotavirus vaccine coverage differs between different socioeconomic areas in Stockholm with the highest vaccine coverage within the most socioeconomically privileged geographic areas, and therefore our results may only present a part of the county’s inhabitants.
Further, similar studies of parental attitudes toward the rotavirus vaccination within fathers as well as in less socioeconomically privileged context would be of great value, such as similar studies within groups of vaccine hesitant parents.
Conclusions
All parents in our study wanted to protect their children from suffering and wanted the best for their children. Some wanted this by vaccinating their child in order to avoid rotavirus infection and some wanted to avoid suffering by not vaccinating their child because of concerns about the side effects. This is important knowledge for understanding parents’ decisions on vaccines. Most results are in line with previous literature and point out similar patterns of parental attitudes toward vaccines, even in a Swedish context when the rotavirus vaccination is introduced.
Footnotes
Acknowledgement
We are grateful to all participants in the study, to health-care nurses who helped us select the parents, and to Asli Kulane who introduced us to qualitative analysis.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Department of Communicable Disease Control and Prevention at Stockholm County Council. This research did not receive any commercial funding.