The decision to immunise or not is complex with perceptions of risks of vaccines, diseases and robustness of the child's health to be considered. In this study we have identified and clarified differences in perception between complete, incomplete and non-immunisers and also identified similarities between all mothers with respect to the decision to immunise their young children.
While the decision to immunise young children can be understood to some extent in the context of perceptions of severity and susceptibility to disease and benefits and barriers to immunisations, the theories of risk perception and decision-making add a depth of understanding to the differences found between these parents in terms of their perceptions and interpretations of what is risky and what is not. Two aspects in particular appear to be important: the familiarity or unfamiliarity with the disease and perceived control over risks or outcomes. Thus, perceptions of severity of disease are influenced by the unfamiliarity of the disease and/or the perception that these diseases will have uncontrollable outcomes. That is, diseases with which parents are least familiar are perceived as more severe than those with which parents are more familiar and therefore worth taking preventive action. Being a familiar disease contributed to delays in immunisation, or not immunising as these familiar diseases were not considered to be severe.
This finding is congruent with other primary studies. For example, Hilton et al reported 'of all the diseases… measles was the one that parents most commonly reported having as a child. …Indeed their experience of measles often rendered it a less threatening disease…. While parents with no experience of measles entertained the long-term damage it could inflict, those with experiences of it tended to minimise the risks' (p 174, authors' italics). From this it would appear that it is too simplistic to attribute reduction in immunisation uptake to a growing lack of familiarity with diseases because of the success of the immunisation programmes.
Understanding people's perceptions of what can and cannot be controlled is important to understanding their behaviour. There is both an aspect of fearing uncontrollable or unknowable outcomes and therefore taking preventive action and an optimistic belief or an illusion that the environment or risks can be controlled. Unlike the non-immunisers in this study and others, immunisers choose immunisation because they believe they have limited control over their children's environment and contacts. Many believed they could control risks to their own health or were willing to 'take the risk' with their own health.
Parents were less willing to take risks with their children's health than with their own. This was partly because children were perceived as more susceptible than healthy adults and partly because their children were dependent on them making good decisions. This unwillingness to take risks included being cautious of preventive action as well as cautious about diseases. An important barrier to action was the tension between what is 'natural' and medical intervention. For many mothers there was something 'unnatural' about medical intervention. They held a belief that medical intervention was necessary for important diseases but that it was not safe or necessary to use for all problems. Again, this perception that what is unnatural is more risky is congruent with the studies of subjective risk perception, but could not be predicted from the Health Belief Model.
Importantly, the participants believed that the risks of diseases and complications from disease were not equally spread throughout the community. When listening to reports of epidemics, it is not the number of people who are affected but the familiarity or unfamiliarity of the disease and the characteristics of those who had the disease that caused parents to worry about taking preventive action. Poor information or communication creates barriers to immunisation completion which can be understood in terms of the concepts of outrage and ambiguity. Lack of trust and poor communication between providers and parents exacerbated the belief that information was being kept from them. Because they all believed that parents were ultimately responsible for their children, this feeling that information was denied them frustrated and angered them.
This study has used qualitative methods to determine if aspects of theories of risk and decision-making can help to explain parents' decisions about immunising their children. Traditionally qualitative research has been associated with the generation, rather than the testing, of hypotheses, however, this denies a major strength of qualitative research which is to examine theories in the light of data. As such it is a method suited to producing understanding and to generating solutions to problems. We believe this method, therefore, is appropriate to provide a greater understanding of complexities of decision making and perceptions of disease and vaccines and a depth of information not available from large scale quantitatively based surveys. The benefits of using the qualitative method described in this study is the large quantity of detailed information it provides, however, using a small non-randomly selected sample can present problems in determining the generalisabilty of the ensuing information. The results of this study confirm, complement and extend the findings of other studies in this area.
The data that this paper draws on were collected in the late 1990s and some may wonder at their currency. We believe that this might be a problem if the focus of the paper was about which diseases or vaccines are an issue; with scares and controversies these can change over time. The point of this paper however, has been to examine the utility of synthesizing theories of health protective behaviours, risk perception and decision-making. While we recognise that different socio-temporal contexts may create different issues (e.g. the impact of the MMR controversy was substantially greater in the UK than Australia), we argue that the approach we have taken in this paper provides a framework for us to make sense of people's reactions to and perceptions of old (and new) diseases and vaccinations at any time. We therefore think this work can contribute to, and be of particular importance in informing the public health approaches to new flu epidemics. It provides data supporting commentary and critique of the current public health approach to the issues of vaccine risk and immunisation uptake, being that continued provision of better risk information is not the answer.
We have found and would argue that the theories of risk perception and aspects of decision-making under uncertainty have been useful for understanding the differences and similarities between pro-immunisers and non-immunisers, except for the issue of omission bias. Parents in this study, whether immunisers or not, generally did not agree that a negative outcome was preferable or more acceptable from inaction. This finding raises some doubts about the methods and/or generalisability of findings from studies of this phenomenon, which usually involve multiple, similar, hypothetical situations with limited contextual information, presented in mathematical and probabilistic language. Participants in this study responded to these omission bias statements by generally denying that either contributed to their decision to immunise their child.
Implications for Communicating Information About Vaccines and Diseases
Similar findings to this study have been reported by others and have important implications for how public health addresses the issues of trust and communicates risk information. As others have noted there is more to risk communication than providing more facts about risks. To paraphrase Hobson-West, from these studies and critiques, it is clear that education is not the main policy tool and ignorance is not the main enemy for maintaining immunisation uptake.
Drawing on the aspects of subjective perceptions of risk and decision-making under uncertainty, we believe the following needs to be considered in communicating risk information and health messages:
Facts and figures are not interpreted or acted upon rationally: dread, catastrophic potential and familiarity with the risk influences interpretation and action
People act as lay epidemiologists. Thus providing information about risks as though everyone has the same risk makes the advice unbelievable and can be discounted
Parents are more willing to take risks about their own health than with their children's health but this greater caution about their children's health does not automatically mean they will accept medical intervention
From the theory of subjective perception of risk people may well be wary of novel vaccines or therapies (manmade versus natural risks) hence there may be some hesitation in the uptake of such vaccines
People will discount their risks-'the people affected are not like me'. This may have implications for how people will assess their risk of being badly affected by any outbreak of new strains of influenza such as H1N1.
Clear communication which involves listening to, and not dismissing people's concerns, is valued.