Four main themes were extracted from the focus group discussions. Some of the main themes were divided into sub-themes. The themes are summarized below with relevant quotes of participants. Results of Moroccan, Turkish, and participants with other ethnic backgrounds were described together, because the findings were mostly similar.
All participants were female. Most participants had one child (n = 13), 8 participants had two children, 5 participants had three children, four participants had four children, two participants had six children, and for one participant, the family size was unknown.
Participation NIP and child welfare center
All participants confirmed that their children so far had received all NIP-vaccinations, corresponding to the Dutch NIP schedule.
Child welfare center visitation
Participants from all groups were familiar with the CWC for both health check-ups and receiving vaccinations for their child. Nearly all participants visited the same CWC in their neighborhood, and perceived CWC visitation as self-evident and important: ‘I visit with my child the CWC. We [the mothers] all have the same opinion, that it is just very important’ (Moroccan participant). Another Moroccan participant said: ‘Yes, it is obvious; it is just a normal thing to do [visiting the CWC]’.
For almost all participants, the CWC was well accessible: ‘No, I have no problems in accessing the Child Welfare Centre’ (Turkish participant). A few participants mentioned that the CWC is located too far from their homes, and some participants mentioned that the distance negatively influenced the CWC visitation, but not when her child had to receive vaccinations: ‘I didn’t go the first time, I had an appointment, but I didn’t go. It [the CWC] was just too far away. After that I did go, because they [children] needed vaccinations, so I went there because of the vaccinations, otherwise I wouldn’t go there’ (Moroccan participant). Another participant said: ‘I think the CWC is located too far, especially when the weather is bad and I need to walk because I do not have a car’ (Moroccan participant).
Satisfaction with CWC services
There were mixed findings about the satisfaction of the provision of NIP vaccinations, health check-ups and the approach of childhood vaccine providers (CVPs). Most participants were unsatisfied with the limited consultation time. Moroccan and Turkish participants indicated that they did not receive enough attention, and that there was not enough time to ask questions during CWC visitations: ‘Here [at the CWC] everything goes quick, quick, quick’ (Moroccan participant). Another Turkish participant said: ‘They never have a conversation with you; consults always take place automatically and very quick. Many parents regret that because they don’t receive enough attention.’ In the mixed groups, participants emphasized that they did not receive enough information, but they perceived the CWC as accessible for asking questions: ‘They do not further explain what it means. That's really a shame, I think. They give the injections but they do not explain how and what. However, when I do have questions, I think it is possible to ask them’ (Participant mixed group). Two Turkish participants were not satisfied about the vaccination skills of the CVPs, but they indicated that this did not influence their decision to vaccinate: ‘Some CWC nurses, they don’t inject well. They are so rough when they give the injection. I did not like that but I did not say anything about it’ (Turkish participant).
Factors influencing parental decision making
Several factors influenced the decision of participants to vaccinate their child, such as their attitude towards the NIP, cultural and religious aspects, perceived social norm, negative experiences with vaccination and adverse events, knowledge level and understanding of the NIP, and practical issues.
Attitude towards vaccination
Almost all participants had a positive attitude towards childhood vaccination and mentioned that vaccination of their children is important because it benefits and protects their children’s health: ‘I did not really thought about whether to vaccinate or not, I thought it is just normal, you should be protected against diseases. I actually thought it was necessary. You hear it for years that children are being vaccinated and we have all been vaccinated ourselves. So it is just logical that they [the children] get vaccinated’ (Turkish participant). Most participants perceived vaccination as self-evident and some participants thought that participating in the NIP is mandatory: ‘It is so obvious that you think that it is obligatory’ (Moroccan participant). Turkish participants emphasised that it is important and logical to follow the advice of experts and CVPs: ‘So very often you think as a parent; they are the experts, they know better than us’ (Turkish participant). Another Turkish participant said: ‘If the CVP says it is good, then I assume that it is good. I have confidence in their advice’.
Cultural aspects and religion
Most of the (Muslim) participants indicated that according to Islam, vaccination was considered as something beneficial: ‘Our faith tells us that we must protect our body well. That is our starting point’ (Turkish participant). Another participant said: ‘We also get vaccinated in Morocco, it is just important to protect your children against diseases’ (Moroccan participant).
Perceived social norm
Most participants indicated that they had no conversations with neighbors, friends or family about vaccinations. ‘No, nobody talks about it. I think most mothers realize that it is very important and that it is something that has to be done for the health of their child’ (Moroccan participant). Although most participants did not discuss vaccination with their social environment, for some Turkish participants’ feelings of uncertainty about negative CWC experiences were a subject to discuss with friends or neighbors: ‘I asked my friend how it went with vaccinating their child. She told me the same, that they gave the injection all of a sudden. So I thought: okay, it is normal’ (Turkish participant).
Negative experiences with vaccination and adverse events
Some participants had experience of adverse reactions after vaccinating their child: ‘After my daughter was vaccinated she was sick for a week, she had 40° of fever and vomited. I thought for 8 days that my daughter was dying’ (Moroccan participant). Although this parent had a negative experience with vaccination, this did not influence her decision for future vaccinations: ‘No, I continued to have my daughter vaccinated’ (Moroccan participant). A participant from the mixed group became more afraid of vaccinations because her baby recently had febrile seizures after vaccination: ‘And now I am afraid because every time he gets a shot, he gets high fever. That is why I am afraid of the next shot: will he be okay this time?’ (Participant mixed group).
Some Turkish participants were sometimes worried about the vaccinations: ‘The first time, with your first child, you worry more; what is going to happen, how does he or she respond? I was worried’ (Turkish participant). Another Turkish participant said: ‘You do not get answers about the cause of the reaction. That fear stays in your mind’. Nevertheless, most participants continued vaccinating their child: ‘Yes, even if there are side effects, I will continue with vaccinating my child. Each drug has side effects, then you also do not quit, you also proceed’ (Turkish participant).
Transition and practical issues
None of the participants had problems with missing vaccinations because of transition to The Netherlands: ‘No, it was not a problem. I was instantly referred to the child welfare center when I came from Barcelona to the Netherlands’ (Moroccan participant).
Participants perceived no problems in receiving vaccination invitations or responding to calls. CWC appointments were clear and feasible to them: ‘Yes, everything was clear to me, I never had problems with that’ (Moroccan participant). Some participants had questions about how tocontinue the vaccination schedule when they went on holiday to their home country, but none of them missed vaccinations due to holiday abroad: ‘Then I called [the CWC] and they rescheduled my appointment’ (Turkish participant).
Level of knowledge and understanding NIP
The majority of participants perceived their knowledge of vaccinations and the NIP as insufficient. Most participants know in general when the vaccines are given, but do not know against what infectious diseases the vaccines will protect: ‘You don’t know what these injections are for. You only hear the abbreviation [of the vaccine] when they are given, but not for what kind of diseases the injections are for’ (Moroccan participant). ‘You have them [the children] vaccinated but you don’t know what kind of vaccinations they get’ (Turkish participant).
Several factors concerning NIP-information were extracted from the focus groups: evaluation of the received NIP information, perception of the language of the received information, information-seeking behavior, and information need of the participants.
Evaluation of received information
Almost all Moroccan participants evaluated the amount and content of information they received from CVPs as insufficient: ‘Because they don’t give you an explanation during vaccination…you just receive the jabs and you are finished. How many shots you get and for which diseases, that has actually never been told’ (Moroccan participant).
Among Turkish participants, experiences with receiving information varied. Turkish participants were more satisfied with the amount and content of information they received from CVPs and the Public Health Institute (PHI): ‘Yes, it was sufficient’ (Turkish participant). Some participants received information about vaccination when they visited the CWC: ‘Yes, when I went to the CWC they explained what can happen, or told me that I need to keep an eye on something. They told me that every time I visited the CWC’ (Turkish participant). Others said they did not receive information: ‘No, I did not get information. Normally in Turkey, they give some explanation before injecting, but in the Netherlands I did not get that’ (Turkish participant). In the mixed groups, most participants indicated that they received information by mail but they received little or no information from CVPs: ‘You do not really receive information about it. You only receive the information leaflet’ (Participant mixed group).
The information leaflet from the Public Health Institute (PHI) with information about the NIP was received and read by most Turkish participants: ‘Yes, I received it [the leaflet] together with the invitation letter’ (Turkish participant). Among Moroccan participants, the leaflet was less well known: ‘I never received it. I never received information about vaccinations’ (Moroccan participant). The leaflet was poorly read by Moroccan and Turkish participants: ‘No I never read it’ (Moroccan participant mixed group). Only some participants from the mixed group read it: ‘Yes I have read the brochure’ (Participant mixed group).
Perception of language received information
In both Moroccan and Turkish groups, the language of the education material was considered an obstacle for reading and understanding the content. Moroccan participants emphasized that there is a substantial group of Moroccans who do not understand the Dutch language, and therefore are not able to read the information leaflet in Dutch: ‘There are many people here in the district who can’t speak the Dutch language and are not able to read it. So, I think when you give a leaflet, it is important to give it in their own language too’ (Moroccan participant). Also in the Turkish group, a few participants could not read the information material due to language barrier: ‘It is difficult for me; I do not understand the Dutch language’ (Turkish participant). This was the same for the non-Dutch participants in the mixed group: ‘I have problems with the Dutch language. I cannot read Dutch, I do not understand all the words’ (Non- Dutch participant mixed group). Some participants asked their husband or a friend to translate the information: ‘My husband reads it for me, explains to me what it means’ (Moroccan participant mixed group).
Most Turkish and Moroccan participants would like to receive information in respectively Turkish, Arabic and Berber language:’Yes I want it in Turkish… because in that case, I know at least why my child receives that vaccination, otherwise I don’t know’ (Turkish participant). Participants indicated that provision of information in their own language would not influence their vaccination decision: ‘I don’t think so. I will get the vaccines, no matter what’ (Turkish participant).
Information seeking behavior
Most of the time, the participants used the CVPs and the Internet as a source to get information about vaccination. Some Turkish participants searched for additional information in their own language on the Internet, or asked questions at CVPs: ‘In advance I thought about what questions I would like to ask, what I wanted to know and then she [the CVP] explained it…because of her explanation I knew what to expect’ (Turkish participant).
Some Moroccan participants and participants from the mixed groups mentioned that they sometimes asked for more information about vaccination at CVPs: ‘Yes, I ask questions before my child gets the injection. I ask first, and then my child gets the vaccination’ (Participant mixed group). Sometimes (when possible) they talked with a doctor in their own language. Other Moroccan participants did not realize that they could ask for more information, or time constraints kept them from asking for information: ‘No, at that time, you don’t think about it’ (Moroccan participant).
Some participants searched for online information when there was a possible side effect: ‘I will search for information on the Internet, if I know my child gets ill from the injections. When everything goes well, I will not search for information’ (Moroccan participant). In the mixed groups, the use of the Internet varied. Some participants indicated that they regularly used the Internet to find more information about vaccinations: ‘I read a lot in my own language. I search for information on the Internet’ (Participant mixed group). Most of them used the search engine Google. Other participants did not search online for vaccination information: ‘I never searched for information myself. I don’t know why…I just not really thought about it’ (Participant mixed group).
Most participants preferred more oral information from CVPs during CWC consultations: ‘That they explain where the vaccinations are for, that they give more face-to-face information during the consult, not that you just have to get your information from the leaflet. I prefer spoken information, because I will remember it better’ (Participant mixed group).
Participants would like to be more informed about the targeted infectious diseases and the prevalence of the diseases: ‘More information about the vaccinations themselves [….] more information about where the vaccinations are good for, and what they protect for’ (Moroccan participant).
Moroccan participants also desired more information about drawbacks of vaccination from the RIVM, because it would enable them to make a well-informed decision: ‘You hear things in the media but you don’t know whether that information is right. I would like to receive complete information from the RIVM with advantages and disadvantages. When we hear the pro’s and con’s from the RIVM about vaccination, we can make a better choice’ (Moroccan participant).
Attitude towards future vaccinations
Participants had different opinions about possible future NIP vaccinations. Some participants were suspicious towards new vaccinations: ‘Vaccination against diphtheria or tetanus, that kind of diseases, is required for all your children, you simply choose for that. But for new vaccines, which are new to the market and are not thoroughly investigated, I have doubts about that’ (Turkish participant). In case of new vaccines, parents would like to receive information about reasons for introduction of the new vaccine, severity of the disease and the risk for their children to get the disease: ‘I would think about it and would like to know what kind of vaccine it is, against what kind of disease it will protect, and why the vaccine is introduced. In case of a new vaccine, I would not just vaccinate my child.’ (Turkish participant). Other participants were less critical towards possible new future NIP- vaccinations: ‘It does not matter to me, if it is necessary, then it is necessary. I assume that every vaccination, when added, is needed’ (Participant mixed group).