Addressing Issues of Vaccination Literacy and Psychological Empowerment in the Measles-Mumps-Rubella (MMR) Vaccination Decision-Making

A Qualitative Study

Marta Fadda; Miriam K. Depping; Peter J. Schulz


BMC Public Health. 2015;15(836) 

In This Article


Recruitment and Participants

Qualitative methods are most appropriate when a better understanding of a phenomenon is sought,[74] or when a theory needs to be built. Individual interviews rather than focus groups were chosen as they allow to obtain a deeper individual understanding of parents' vaccination literacy and empowerment in the MMR vaccination decision making.

Participants were recruited in the Canton of Ticino (Italian-speaking Switzerland). To maximize the variability of our sample's experiences, we employed a diverse recruiting system. Invitation flyers were sent to pediatricians and gynecologists, distributed at local public and private nursery schools, pre-schools, supermarkets, pharmacies, yoga and baby splash classes. In addition, invitations were circulated in a number of public spaces and printed in a number of local newspapers. Participation was optional and participants received a 20.- CHF shopping voucher as compensation.

Eligibility criteria for this study included: (a) being parent of at least one child under the age of 12 months (since the administration of the first dose of the MMR vaccination is recommended in Switzerland when the child turns 1-year-old, our inclusion criteria allowed to meet parents during their vaccination decision-making); (b) being a permanent resident in the Canton of Ticino.


The Ethical Committee of Canton Ticino gave ethical approval to the study (Rif. CE 2770). Each participant signed a consent form prior to the interview.

Data Collection

We conducted 20 face-to-face, semi-structured individual interviews in Italian, which lasted approximately 30 min each. We used semi-structured interviews in order to have a flexible grid of structural and open questions, allow each interviewee to describe his or her experience and introduce new themes spontaneously. The interview guide was developed on the basis of the Health Empowerment Model[64] to elicit detailed information on: (1) confidence in one's MMR vaccination decision; (2) vaccination literacy, including general beliefs, procedural knowledge, subjective knowledge, perceived outcomes of MMR, and information-seeking behaviors;[75,76] (3) psychological empowerment, according to its conceptualization into the four sub-dimensions of meaningfulness, impact, self-efficacy, and self-determination;[64] (4) social influences; (5) reactions to MMR-related information; (6) usage of complementary and alternative medicine (CAM); (7) risk perception of both measles and MMR side effects (comprising severity and susceptibility of their respective consequences); (8) barriers to the decision. See Additional file 1 for a detailed interview schedule containing all questions.

The vast majority of the interviews were conducted by the first author, who has a background in social anthropology, either at parent's house, workplace, or at the University, according to their preference. To assess children's age and collect parents' socio-demographic characteristics (age, origin, education, number and age of children), a short questionnaire was sent by email to each participant upon completion of the interview.

If participants explicitly gave us permission, they were sent official information leaflets on measles and the MMR vaccination together with the gift card and a debriefing letter after the interview.

Data collection and data analysis were carried out simultaneously over a period of 5 months beginning in January 2014. Data collection ceased once data saturation was reached, that is when it was decided that additional interviews would not yield new data, but only confirm what was found in previous interviews.[77]


Each interview was recorded, using a digital voice recorder, and transcribed verbatim by the main researcher and the research assistant (both native Italian speakers) within 3 days from completion of the interview. The transcripts were read several times by the main researcher to become familiar with the content, and they were later entered into NVivo for the coding (QSR International Pty Ltd. Version 10, 2012). Both transcription and analysis of the interviews were conducted in the original language (Italian) to avoid missing significant elements during the translation process. An inductive thematic approach[78] was used for the analysis of the data. Meaningful utterances were grouped and later categorized under several labels. Labels were subsequently organized hierarchically,[79] and similar labels were then gathered into bigger themes. Preliminary themes, labels and utterances were then discussed with two senior qualitative researchers who provided feedbacks in relation to the ongoing analysis. At the end of this process, all transcripts were read again to establish logical links between different themes. The results of the inductive thematic analysis will be described in the following section, while they will be interpreted in the discussion section by making the link to our research question.