1“ NW MSU H, m ”t 1]“ H“ [1 [TIM 3 1293 00869 0228 RETURNING MATERIALS: Place in book drop to LIBRARJES remove this checkout from 53!! your record. FINES NH] be charged if book is returned after the date stamped be10w. Ema 0 7 1&9} A‘fi? ‘;JH3;Q FATHERS PERCEPTIONS OF COMMON CHILDHOOD DISEASES AND VACCINES AS THEY INFLUENCE THE INTENT TO ACQUIRE INHUNIZATIONS FOR A CHILD by L. S. O'Connor A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1985 copyright by L.S. O'Connor 1985 ABSTRACT FATHERS PERCEPTIONS OF COMMON CHILDHOOD DISEASES AND VACCINES AS THEY INFLUENCE THE INTENT TO ACQUIRE IMMUNIZATIONS FOR A CHILD by L.S. O'Connor A descriptive study of fathers with a newborn child was conducted to identify the relationship between their perceptions of susceptibility to common childhood diseases, the perceived severity of that disease, the perceived benefit of taking action to prevent common childhood diseases, the perceived barriers to taking that action and the fathers intent to acquire immunization for his newborn child. Other findings discussed are motivational "cues to action" and General Health Motivation as it influenced the fathers intent to acquire immunization for his child. Data was collected from fifty fathers of a newly delivered and seemingly healthy child. Data was analyzed using Pearson product-moment correlations and descriptive statistics. Due to lack of variability in response to the dependent variable, no statistically significant relationships could be found between perceived susceptibility, severity, benefits, barriers and intent to acquire immunization. In conclusion, although statistical significance could not be achieved, the investigator found that the nurse should recognize the part fathers play in obtaining health care for their children. Nurses must assist the father to understand how best to obtain the goal of optimal health for his child/children. This thesis is dedicated to my research partner and good friend, Heidi Froemke. ”Your friend is your needs answered... in friendship, all thoughts, all desires, all expectations are born and shared... And let your best be for your friend. And, in the sweetness of friendship, let there be laughter and sharing of pleasures." from The Prophet by Kahlil Gabran ACKNOWLEDGEMENT Without the efforts of many people, this study could not have been successfully completed. The advice and direction of my thesis committee is appreciated. Thank you to Barbara Given, Ph.D., for serving as thesis advisor, and to Patricia Bednarz, M.N., and Patty Peek, M.N., for serving as committee members. A special thank you is reserved for Dennis Murray, M.D. His continued enthusiasm and willingness to meet on short notice at the "Western White House” did much to broaden my understanding of the research process. The aid and advice of Andrea Doughty, Ph.D., who acted as statistical consultant, and Jayne Yoder, who typed and edited without complaint is gratefully acknowledged. Thanks also to the nurses and doctors from the obstetrical unit of St. Lawrence Hospital who aided in the collection of data. Many other people provided support, encouragement and humor and need to be mentioned. My classmates, my parents, Helen Froemke, co-workers from Lansing Community College Department of Health Careers and my children, Mary, Asa and Gabriel, all have my thanks. My special appreciate is reserved for my research partner, Heidi Froemke. Her support, encouragement and sense of humor, even at two in the morning, did much to contribute to the success of this project and will never be forgotten. TABLE OF LIST OF TABLES O O O O O O O O 0 LIST OF FIGURES . . . . . . . . THE PROBLEM Introduction . . . . . . Statement of the Problem . Purpose . . . . . . . . . Hypotheses . . . . . . . . Definition of Terms . . . General Use of the Study . Limitations . . . . . . . Assumptions of the Study . CONCEPTUAL FRAMEWORK Overview . . . . . . . . . The Health Belief Model . Parental Perceptions . . . Perceived Susceptibility . Perceived Severity . . . . Perceived Benefits . . . . Perceived Barriers . . . . CONTENTS "Cues to Action" as a Motivational Action . . . . . . . . . General Health Motivation Modifying Factors . . . . Summary . . . . . . . . . Parents . . . . . . . . . xix DOKOQNO‘U'I-o l2 i3 15 16 i6 18 19 20 20 21 22 2h Vaccines . . . . . . . . . . . . . . . . . . . Immunization . . . . . . . . . . . . . . . . . The Preschool Child and Childhood Diseases . . Relation to Nursing Theory . . . . . . . . . . Integration and Schematic Representation of Conceptual "Ode' s O O O O O O O O O O O O O O I O O O C Sumary O O O O O O O O O O O O O O O O O O 0 REVIEW OF THE LITERATURE Introduction . . . . . . . . . . . . . . . . . Childhood Disease and Vaccines . . . . . . . . Measles . . . . . . . . . . . . . . . . . . . Pertussis . . . . . . . . . . . . . . . . . . Health Belief Model as it Describes Preventive Behavior . . . . . . . . . . . . . . . . . . Likelihood of Parents Taking Health Action . . The Health Belief Model and Fathers Preventive Behavior . . . . . . . . . . . . . . . . . . Modifying and Motivation Factors . . . . . . . sumary I O O O O O O O O O O O O O O O O O O METHODOLOGY Overview . . . . . . . . . . . . . . . . . . . Hypotheses . . . . . . . . . . . . . . . . . . Sample . . . . . . . . . . . . . . . . . . . . Data Collection Site . . . . . . . . . . . . . Data Collection Procedure . . . . . . . . . Development of the Instrument . . . . . . . . Operational Definitions of Study Variables . vi 27 27 29 31 35 37 38 38 #2 1+5 50 SI 57 65 71 73 7h 75 76 76 78 79 Scoring . . . . . . . . . . . . . Pretest of Instrument . . . . . . Statistical Analysis of Data . . . Protection of Human Rights . . . . Study Division . . . . . . . . . . sum ry O O O O O O O O O O O O 0 DATA PRESENTATION Introduction . . . . . . . . . . . Study Sample . . . . . . . . . Sociodemographic Descriptors . Modifying Factors . . . . . . Cues to Action . . . . . . . . Open Ended Questions . . . . . Dependent Measure-Intent to Acquire Health Belief Model . . . . . . . Factor Analysis of Health Belief Model Reliability of the Health Belief Model Correlation Matrix . . . . . . . . Presentation of Data Related to Research Subscales . . Instrument . Comparison of Mothers and Father . . . . Sociodemographic Descriptors . . . General Health Motivation . . . Correct vs. Incorrect Age . . . . Summary . . . . . . . . . . . . . vii Hypotheses 81 82 82 83 8h 85 86 86 86 90 90 91 93 93 9h 95 97 98 99 99 105 106 107 VI. SUMMARY INTERPRETATION AND IMPLICATIONS Over Desc Inte view . . . . . . . . . . . . . . . . . riptors of Study Sample . . . . . . . Hypothesis I . . . . . . . . . . . . . Hypothesis II . . . . . . . . . . . . Hypothesis III . . . . . . . . . . . . Hypothesis IV . . . . . . . . . . . . Cues to Action . . . . . . . . . . . . General Health Motivation . . . . . . Correct vs. Incorrect Age . . . . . . Hypothesis V . . . . . . . . . . . . . Hypothesis VI . . . . . . . . . . . . Hypothesis VII . . . . . . . . . . . . rpretation and Limitations of Findings sumry O O O O O O I O O O O I I O O O O Impl Impl Impl ications for Nursing Education . . . . ications for Nursing Research . . . . ications for Nursing Practice . . . . sumry O O O O O O O O O O O O O O O O O BIBLIOGRAP APPENDIX A HY . . . . . . . . . . . . . . . . . Human Subjects Review Approval . . . Hospital Approval of Study Protocol Selection Criteria Checklist . . . . Letter of Explanation . . . . . . . Study Questionnaire . . . . . . . . Telephone Consent . . . . . . . . . viii 109 110 115 116 118 120 121 123 12“ 126 126 126 127 128 129 130 132 138 139 xi xix xx xxi xxii xxix 10. LIST OF TABLES Age Distribution of Fathers . . . . . . . . . . . . . . . 87 Distribution of Subjects by Area of Residence . . . . . . 87 Distribution of Fathers' Marital Status . . . . . . . . . 88 Distribution of Fathers Education . . . . . . . . . . . . 89 Parent Combined Annual Household Income . . . . . . . . . 89 Reliability Coefficient Alphas for the Health Belief Model Subscales . . . . . . . . . . . . . . . . . . . . 95 Range, Mean, Mode, SD of HBM Subscales for Fathers . . . 96 Correlation Matrix for Susceptibility, Severity, Benefits, and General Health Motivation . . . . . . . . 97 Distribution of Mothers and Fathers Reasons for Immunizing at Specific Ages . . . . . . . . . . . . . . 102 T-tests on Maternal vs. Paternal Responses to the Health Bel ief "Odel SUbscales O O O C O O O O O O O O O O O 0 10h l. 2. LIST OF FIGURES Health Belief Model . . . . . . . . . . . . . . . . . Integration and Schematic Representation of Conceptual "Ode! s O O O O C C O O C O O I O O O O O O O C O O O 17 31 CHAPTER I THE PROBLEM* Introduction There is concern among public health officials concerning the potentially serious situation of the immunization status of the nation's population. According to the U.S. Immunization Survey (1973, 1977) significant proportions of the U.S. child population was inadequately immunized. Even though obtaining immunizations is one of the most accepted preventive child health measures, national surveys as of 1977 (Blaesing, 1977) indicated that 5.8 million of the nearly IA million, one to four-year olds in this country were unprotected against childhood diseases. Five years later, h,358 cases of whooping cough and at least 15 deaths were reported to the Centers for Disease Control. Researchers believe that the number of children contracting the disease may be 10 times greater than reported. Additionally, two years after the federal government's target date for eliminating measles in the U.S.A., measles, a once-common childhood disease is on the rise again, up BA: from a year ago with a total of 2,322 reported for 198A (”Measles Jump," 198A). In 1981, the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program in Michigan, alone, health-screened 118,839 children. Of this number, 78,713 referrals were made for health concerns of which 16,272 or 202 were for lack of one or more immunizations (Michigan Dept. of Public Health, 1981). *This chapter written in collaboration with H. Froemke (1985). As recently as December 198%, the New York Times carried a feature article calling for medical reform and citing the alanming figures that #02 of all preschool children and 602 of non-white preschool children are not fully immunized against common childhood diseases. Measles outbreaks continue to be reported from places where preschool children are concentrated. This was reported the same year that the occurrence of measles reached its lowest level since national reporting of measles began in 1912 (CDC, 1982, February 5). During the 1970's, reported cases of communicable diseases took a significant upswing. Measles outbreaks across the country, from 1981 to 1983 reported significantly greater numbers of cases in the preschool and high school to young adult age groups (CDC, 1982, December 17; March 19; April 16; 1983, April 22). Wehrle and Wilkins (1981) explain: ”With increased vaccine usage and the resulting declining incidence of naturally acquired disease, public apathy and neglect of continuing programs by public health agencies can be expected. The wide publicity given to untoward vaccine reactions by the news media also has had a deterrent effect. Immunization requirements for school entry, for certain occupations, and for the armed forces have counteracted at least some of the lack of interest in immunization programs. Poliomyelitis is, in the United States, the only disease for which the vaccine was awaited eagerly and embraced enthusiastically by a nervous public" (pg. 36%). Much of the debate on immunization in recent years has focused on the vaccine against whooping cough. Until an inoculation was developed in the 1930's the respiratory disease afflicted hundreds of thousands of people. In the U.S. alone, in 193A, it killed 7,000, mostly children. In Japan and England of 1980 and 1982, respectively (Kanai, 1980; CDC, 1982, December 3), widespread epidemics of pertussis occurred following adverse publicity by the media concerning neurotoxic reactions to pertussis vaccine. This followed in the wake of aggressive immunization programs for both countries, who were, at the time, enjoying low prevalence of the disease. The United States, too, may not escape such media campaigns. The Portland Oregonian, in June 198A, suggests ”a dark underside to the long pattern of vaccine successes most people take for granted that could unravel these great medical advances and perhaps even make the disease they now can prevent a threat once again" (Beck, 1984). This same year, the Idaho Statesman published the following: "A recent study by an American Medical Association commission estimated that A3 children suffer brain damage each year after receiving whooping cough vaccine...in the United States, about 10 people a year suffer side effects from the measles, mumps and rubella vaccines. Five people, mostly unimmunized adults annually contract poliomyelitis after coming in contact with vaccinated children (198A). Additionally, Dissatisfied Parents Together, an organization of families of children adversely affected by vaccine, have banded to support one another, to keep abreast of immunization complications, to inform the public and put pressure on the government. These parents maintain the medical profession is understating the particular risks of the vaccine against whooping cough. This same pressure finds Senator Paula Hawkins, R-Florida, pushing legislation in Congress to get financial help to those individuals harmed by immunizations (Sun, 1985). In recent years an undertone of menace has crept onto the scene. Parents are raising questions and filing and winning multimillion-dollar lawsuits over the rare cases in which reactions to a vaccine have caused brain damage or even death. Public health experts express concern that the recent spate of court judgements could threaten the supply of vaccines (”Academy Pertussis," I98h). Tight supplies arose when Wyeth Laboratories, two of three U.S. companies manufacturing the pertussis vaccine, announced in 198A they were halting production. The decisions were prompted by increasing litigation expenses and liability exposure from suits alleging vaccine injury and increased cost of insurance coverage. As late as February of 1985, spot shortages of OPT vaccine continue. A survey of 583 physicians by eight health agencies shows about a third had difficulty obtaining the vaccine (Findlay, I985). The Centers for Disease control in Atlanta optimistically predicted that the short supply of vaccines would ease by the end of 1985. One is left to wonder how the "Immunization Objectives for 1990" (Hinman 8 Jordan, 1980) will be accomplished. Briefly, these goals state that by I990, at least 902 of children have their basic immunization series by the age of two years; and at least 95% of children in day care centers and kindergarten through grade 12 are fully immunized. It would appear that what health care considers medically expedient, the public, in part, views as both medically unacceptable and socially unnecessary. Health care has turned more and more in recent years to the social and behavioral sciences for a better understanding of the forces which shape health habits, life-style, and influence health knowledge, attitudes and practices. The Health Belief Model (Rosenstock, 197“) provides a framework on which to build a total concept to determine why some people behave the way they do in relation to their health. The future, thanks to medical technology, holds an ever increasing number of vaccines for communicable disease (Hinman 8 Jordan, 1983). What the response of the public will be to these medical advances remains uncertain. Statement of the Problem Health care providers are required to educate an apathetic and, at times, resistant individual whose child is in a good state of health, to accept what can be an uncomfortable and occasionally hazardous procedure, and to provide protection against a disease that seldom occurs. There is a need, therefore, to describe parental similarities and differences in parental perceptions (mothers vs. fathers) concerning childhood disease and vaccines, and to identify their intent to acquire immunizations for their children. For the purpose of this research, the investigators have chosen to divide the study into two parts. Therefore, O'Connor (1985) will investigate fathers' perceptions of childhood diseases and vaccines as they influence the acquiring of immunizations for their children. Froemke (1985) will investigate mothers perceptions of childhood diseases and vaccines as they influence the acquiring of immunizations for their children. Finally, the authors will include an analysis of the data comparing mothers' and fathers' perceptions of childhood disease, vaccines and immunizations. Purpose The purpose of this study is to describe those parental perceptions of childhood diseases and vaccines as they influence acquiring immunizations for their children. An increased understanding of these perceptions as they relate to immunization behavior will assist health care professionals to make knowledgeable assessments of a parent's potential for compliance to immunization schedules, to predict behavior, and to plan appropriate interventions relative to those perceptions which will modify or change health behavior. Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis VII: Hypotheses There is a positive relationship between a father's perception of susceptibility to common childhood disease and the intent to acquire immunizations for a child. There is a positive relationship between a father's perception of severity of common childhood diseases and the intent to acquiring of immunizations for a child. There is a positive relationship between a father's perception of benefits of vaccines and the intent to acquire immunizations for a child. There is an inverse relationship between a father's perception of barriers to immunization and the intent to acquire immunizations for a child. There is a positive relationship between fathers' perceptions of susceptibility to common childhood disease and mothers' perceptions of susceptibility to common childhood disease. There is a positive relationship between fathers' perceptions of severity of common childhood diseases and mothers' perceptions of severity of common childhood diseases. There is a positive relationship between fathers' perceptions of benefits of a vaccine and mothers' perceptions of benefits of a vaccine. Hypothesis VIII: There is a positive relationship between fathers' perception of the barriers to immunization and mothers' perception of the barriers to immunization. Definition of Terms Fathers: The biological father of the child. Epllp: "Normal” newborns (those not born with genetic defects, congenital malformations) and with no restriction placed on the number, sex, physical or mental conditions of other children in the family. Childhood diseases: The common childhood communicable diseases of diphtheria, pertussis, tetanus, polio, measles, rubella and mumps. Vaccines: Vaccines included in this study are measles, mumps, rubella, diphtheria, pertussis, tetanus and polio. Immunization: The process of administering vaccine. The basic series of immunizations as recommended by the American Academy of Pediatrics (AAP) includes the optimal basic series as four DPT (diphtheria, pertussis, tetanus), three DPV (oral polio vaccine) and one measles, one rubella and one mumps (MMR) vaccination following this schedule: app VACCINE 2 months DPT, TOPV a months DPT, TOPV 6 months DPT 15 months Measles, Mumps, Rubella (MMR) 18 months DPT, TOPV h-6 years DPT, TOPV Intent to Acquire: A parent(s) positive indication that he/she will have a child/children immunized. Perceived Susceptibiligy: The subjective risk that a child may contract or develop a disease or condition (Rosenstock, 197A). Perceived Severipy: The degree of worry created by the thought of a disease as well as by the kinds of difficulties the individual believes a given health condition will create for them and/or the medical/clinical consequences of a health problem (Rosenstock, 197A). Perceived Benefits: The belief that a given action will be effective in reducing the threat of disease (Rosenstock, 197A). Perceived Barriers: The belief that an action itself may be inconvenient, expensive, unpleasant, painful or upsetting, thereby resulting in avoidance (Rosenstock, 197“). General Use of the Study Using the original Health Belief Model (Rosenstock, 1974) as the theoretical framework for study to determine health beliefs, perceptions of susceptibility, severity, benefits and barriers identified, will be related to childhood disease, vaccines and immunizations only. Results may be used by the health care provider to influence preventive behavior and increase the validity of the Health Belief Model as a theoretical framework for predicting the intent to acquire immunizations. -10- Limitations Limitations of the study are: 1. Subjects who agree to participate in this study may be different from those who refuse. Therefore, it is possible that research findings are not representative of all parents. Individual perceptions of the meaning of answer-choices may affect individual responses. The small number of patients participating in the study due to availability, result in data which are not generalizable to larger populations. The study participants are a convenience sample selected from one hospital setting. Random selection of study participants is not employed. The variables measured cannot be assumed to be normally distributed. Therefore, a potential for bias does exist. The "intent to acquire” does not prove that a behavior (immunization) will occur. Parents may be too ”new” to accurately measure perceptions, thereby biasing the results. Assumptions of the Study For the purpose of this study, the investigators make the following assumptions: 1. Health-related perceptions affect health-related behaviors. -11- 2. The concepts of perceived susceptibility, severity, benefits and barriers, as defined in this study, are real and measureable phenomena. 3. Immunizations against childhood diseases are reasonably safe and effective. A. The immunization schedule recommended by the American Academy of pediatrics is valid. 5. High immunization levels in the general population are of benefit to the health and physical well-being of the United States. This study is divided into two parts: mothers and fathers. For the purpose of clarity, O'Connor (1985) will investigate fathers' perceptions of childhood diseases and vaccines as they influence the acquiring of immunizations for their children. Froemke (1985) will investigate mothers perceptions of childhood disease and vaccines as they influence the acquiring of Immunizations for their children. -12- Chapter II CONCEPTUAL FRAMEWORK* Overview A conceptual framework is presented which integrates the preventive Health Belief Model variables along with modifying and motivational factors with the nursing theory of mutual goal-setting. Parents bring to any interaction with a health care provider the totality of their individual realities, i.e., perceptions. Parent's perceptions about the potential threat of an illness to their child is weighed against the barriers and benefits encountered by seeking immunizations for their children. King's (1981) theory is presented as an organizing framework by which the health care provider may better conceptualize the dynamics of the nurse-parent interaction. The Health Belief Model (Rosenstock, I97“) aids in identifying and organizing parental perceptions within this interaction as they influence health behaviors and the intent to acquire immunizations for their children. Presentation of the conceptual framework, therefore, includes a brief review of the origin of the preventive Health Belief Model; descriptions of the main study variables of perceived susceptibility, perceived severity, perceived benefits, and perceived barriers; a discussion of modifying and motivating factors which may affect individual perceptions (Rosenstock, 197A); and the manner in which King's (1981) theory of nursing can be used to encourage preventive health care behavior. *This chapter written in collaboration with H. Froemke (1985). -13- The Health Belief Model The Health Belief Model was developed to explain preventive health behavior which was defined by Kasl and Cobb (1966) as "any activity undertaken by a person who believes himself to be healthy for the purpose of preventing disease or detecting disease in an asymptomatic stage" (p. 296). The Health Belief Model described by Rosenstock (197“) is based upon the theories of decision making and behavior motivation first proposed by Lewin (1935), who postulated that behavior is derived from positively, negatively, or neutrally valued individual perceptions. Each individual constructs his/her own world view, giving meaning to events, objects or words from the symbolism they represent to the individual rather than from any universal cultural determinant or stereotype. This theoretical framework emphasizes the importance of the individual defining one's own behavior (Wagner, 1970). In developing the Health Belief Model, Rosenstock (I97A) utilized an individually based definition of perception for "it is the world of the perceiver that determines what he will do and not the physical environment, except as the physical environment comes to be represented in the mind of the behaving individual” (p. 2). Rosenstock (197A) integrates the Health Belief Model and Lewin's psychological theories of decision making into a framework which permits the analysis of the individual's process of decision making regarding health behaviors. Sociopsychological variables, then, are used to explain preventive health behavior. Using Rosenstock's (197A) interpretation of Lewin's theory, disease would then be regarded as -1“- negative. An individual would initiate action to change health behavior to avoid or minimize the disease unless that preventive action was perceived by the individual as more negative than the actual disease process. In order for preventive action to occur, the individual would have to feel personally susceptible to the illness, would have to acknowledge the potential severity of the diagnosis, would have to recognize that the preventive action would produce benefits in the form of reduced susceptibility and/or severity, and would have to feel that there would not be insurmountable barriers in taking action. Rosenstock (I97A), working as a social scientist with the public health service, sought to formalize beliefs, attitudes and subjective responses of people in an attempt to understand why preventive measures (immunizations, health screening) are not utilized even when offered at little or no cost. The formulation of the Health Belief Model, therefore, explicates those factors which affect the likelihood that individuals will follow certain recommendations for preventive health action. These beliefs - susceptibility, severity, benefits, and barriers - are the conditions which influence an individual's decision to seek and comply with recommended health care. Later additions to the model postulated that in order for an individual to take an action (a choice or decision) to prevent disease he/she must first be motivated to do so whereupon “cues to action" and "general health motivation" were added as components influencing decision making. -15- For the present research, the preventive Health Belief Model (Rosenstock, 197%) is utilized to describe the individual perceptions of new parents regarding childhood diseases and vaccines and the intent to acquire of immunizations. In the following section, individual variables of perceived susceptibility, severity, benefits and barriers will be examined. Additionally, a discussion of modifying and motivational factors as they influence these perceptions will be included. Parental Perceptions Perception is the process of information extraction (Forgus 8 Malamed, 1966). It is the person's ability to think (to form a judgement or opinion of, to center one's thoughts on, to meditate, or reflect upon), to know (to apprehend as true, to have direct experience of, to have experiential/mental certitude of, to discern the character of), the development of abstractions, concepts and judgements (Bartley, 1958). Thus, perception includes an action as well as a simple receiving of information. King (1981) states that one's perception is related to past experience in the concept of self, to biological inheritance, to educational background, and to socioeconomic groups. Also, the behavior of individuals has been described as human acts. Human acts are then interpreted as actions. Observations of human acts indicate _that the perceptions and judgements of individuals are involved in every type of interaction. ”Since perceptions, judgements, mental -16- action, and reactions are not directly observable, inferences are made about these components of human behavior" (p. 59-60). Perception, therefore is fundamental to all human interactions for from perception flows human behavior. For the purpose of this study, perception is "each individual's representation of reality” (King, 1981, p. 189). The parent, then, is a rational, thinking, sentient individual able to develop and form concepts and judgements about the world around him/her. Such judgements are the parent's own interpretation about reality. The formulation of these perceptions is influenced by many factors including past experience, self-concept, biological inheritance as well as socioeconomic and educational background. From these influences perceptions are shaped and behaviors manifested. Perceived Susceptibility In order to perceive a disease (measles, mumps, etc.) as a potential threat to one's own (or child's) health, the individual must feel both susceptible to the disease, and believe the disease with all its ramifications will be severe. Susceptibility is defined by Rosenstock (197A) as "the subjective risk of contracting a condition" (p. 3). One may believe his/her child can never contract a disease while another believes that there is significant danger of doing so given the same set of circumstances. It is this variability of response which requires further investigation. Perception of susceptibility to an illness thus influences health-care seeking behavior and is a significant factor (See Figure 1) in understanding how beliefs motivate actions. -17- .n .e .39..“ .. «0.....9 “>03... 30.. £0.35. 5...: .2539. v... .25: .2... 5.3.. a .33: A... .2 3.3.9.- 3330». .332... 5...; 03.5.3.2... .o 33...... . a. .30: .020. 5...: 2.... 2 0.50... 0.0.»... 05:9... .0 .2348: 2.0.... .0 .21.!- >....... .o 3...... 3.2.... .o c231... Go... .2352. cove}: 9.2.3 to... 33.3 3.1.5.5.. 3 2.3.9.3 .3..- 3.: .9. 2.2... f 8.3. 2...... mole .o .6228... 3:an v2.3.2. co.uu< on :3 :2... .335 3.....- vos..u.o¢ 6 9......- $3.09.... I~.¢fli¢. ou_~ocoo t.>—Ou..; .. on... o a. use... sill co..u. oc_xo. .9 noun..o... swung» vosuuuwo. “rill >.. oson vo>.ou.o. .. 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The belief that one's child should be exposed to childhood illness in young age while such illnesses will be less severe bears out this perception. Because one's perceptions of susceptibility and severity are strongly cognitive, it is imperative that the individual possess some medical knowledge base in making a decision (Rosenstock, l97h). That is, to have a perception of one's susceptibility to a disease or the severity of that illness, one must have some knowledge of the disease/illness and its potential consequences. Perceived Benefits The physical and psychosocial benefits to be incurred from a preventive health measure (immunization) must be weighed against possible barriers related to the action itself such as cost, inconvenience or painful physical/emotional risks. If the perceived benefits outweigh the barriers to action, it is highly possible that -19- the individual will initiate action without any outside intervention (sanctions, teaching, counseling). If, however, the perceived barriers to action outweigh the benefits, or if both the benefits of action and the barriers to it are costly in terms of material, physical, or emotional consequences, outside intervention may be necessary to instigate an action (Rosenstock, 197“). Therefore, it may be said that the direction an action takes is influenced by the individual's beliefs regarding the effectiveness of available alternatives in reducing the threat of disease. Perceived Barriers Regardless of how many benefits the parent may perceive as the potential result of immunizing a child/children, the positive reward symbolized by the benefits must be weighed against the perceived barriers related to the action of immunization itself. In order for immunization to occur, the barriers must be reduced to a minimum so that the benefits clearly outweigh the barriers. Such barriers include time, cost, fear, physical pain, emotional consequences, risk of injury, as well as illness from vaccine side effects. Barriers which are perceived to be insurmountable will require an intense "cue” to trigger a response to take action. That is, one must be motivated to respond. -20- "Cues to Action“ as a Motivational Influence to take Action In addition to factors which modify the individual's perception of the threat of disease, there are "cues to action" which may trigger the individual to preventive action (see Figure 1). When perceived barriers outweigh perceived benefits the nature and intensity of that ”cue" will need to be critical enough to overcome this unbalanced ratio. The "cue”, therefore, becomes a critical incident which triggers a response to take an action. The "cue to action” serves to make the individual consciously aware of his/her feeling so that they may come to bear upon a particular problem. Such cues may be internal (how one feels physically/emotionally), or external (advice from friends, health care professionals, the media), and are strongly dependent on one's perception of the incident which serves to "remind" him or her of the need to engage in a particular health behavior. Fifty states now require documentation of completed immunizations upon admission of the child to school. Any child not able to produce such "proof" is not allowed to enter school. Therefore, parents are now waiting until a child reaches age four or five to begin immunization. The "cue” is external and becomes the motivational factor in prompting a parent to seek immunization for a child. General Health Hotivation Becker, Drachman, and Kirscht (l972) suggests that the Health Belief Model should include the concept of "general health motivation“ in which behavior is predicted from the value of an outcome and the -21- expectancy that a given action will result in that outcome. While the Health Belief Model traditionally dealt only with the negative aspects of health (the threat of disease or pathological condition) it did not explicitly state that "frank motives towards good health do exist" (p. 853). The general health motivation concept now includes dimensions related to concerns about overall good health. Such concerns may involve parents concern for their own and their families health involving preventive health measures such as adequate nutrition and the taking of vitamins. The general health motivation concept now includes those dimensions related to concerns about overall good health. As a modification of the Health Belief Model, this aspect is included in the study as a determinant of health action. Modifying Factors In addition to the individual perceptual variable of susceptibility, severity, benefits, and barriers previously defined, Becker (197A), postulated that there are a variety of modifying factors which may deter an individuals perception of the threat of disease (see Figure i). For the purpose of this study, demographic, stage of family devel0pment, knowledge of childhood disease and vaccines, and culture-related modifying variables are included. The demographic variables of age, sex, income, education and ethnicity are determined to identify how these related differences influence perceptions. The stage of family development as identified -22- by Duvall (1977) will also be included. That is, does family size and stage of development influence parental perceptions and knowledge about childhood disease, vaccines and immunizations? Summary Applicable to the scope and content of this study, the HBM provides the organizing theory for identifying and understanding the determinants of voluntary health-related actions. The HBM is a practical, clinically applicable framework for intervention, providing potentially modifiable components, i.e., perceptions and beliefs. Therefore, findings have considerable potential for clinical application. Becker, et al. (1977), states, "by knowing which Health Belief Model components are below a level presumed necessary for behavior to occur, the health worker might be able to tailor interventions to suit the particular needs of the targeted group (p. 30). There are implications for further research on the Health Belief Model. Becker, et al. (1977), states various elements of the model require more extensive research in different settings with different population groups and with long run recommendations and therapies. Additionally, other research should be directed at "determining the origins of these beliefs and the conditions under which they are acquired" (p. #0). Janz and Becker (198“) evaluated 10 years of research using the HBM. Results summarized over the decade (l97h-l98h) provide "substantial empirical support” for the HBM (p.l). Perceived barriers -23- proved to be the most powerful of the HBM dimensions across the various study designs and behaviors. While both over all were important, perceived susceptibility was a stronger contributor to understanding preventive health behavior than sick role behavior. The reverse was true for perceived benefits. The most noticeable difference among the HBM dimensions is the relatively lower power of perceived severity with the major exception of its importance to understanding sick role behavior. Janz and Becker (198“) further conclude that "on the basis of the evidence compiled, it is recommended that consideration of HBM dimensions be a part of health education programming" (p. 1). While there are a variety of mechanisms available which are capable of altering attitudes and actions, these approaches or techniques exist without reference to the EEEELE of the beliefs or behaviors that are to be modified. This can only develop from a conceptual or content knowledge of the field. Additionally, the selection of appropriate health education strategies can be derived from examination of perceptions about particular health conditions and from surveys of health beliefs held by various at-risk populations (Becker, et al., 1977). The HBM is not a specific strategy for change, however, those findings, prompted by its use, should inspire innovative interventions for specific areas of interest. The Health Belief Model is not complete in accounting for all variations in how people behave with respect to their health (Drachman, 197A). Sufficient evidence has been gathered to conclude, however, -2“- that the model provides a reliable theoretical and practical foundation for further study. While the HBM specifies relevant attitudes and belief dimensions, it does not recommend any particular intervention strategies for altering them. Also, there exists a need to standardize and refine the tools used to measure the sub-components of susceptibility, severity, benefits, barriers and motivational factors (Janz 5 Becker, 1984). In summary, the HBM is presented as the organizing fraemwork for understanding the influence of internal and external factors upon the development of individual perceptions. These perceptions of severity and susceptibility to disease, balanced against the perceived barriers and benefits presented by the thought of taking an action ultimately influence behavior. Therefore, the HBM provides a framework for conceptualizing the relationship of these perceptions to making a preventive health decision. Thus, it aids the health care provider to both understand and predict health behaviors. It is with this knowledge that a parent may be assessed to understand how perceptions of childhood diseases and vaccines influence their behavior relative to the acquiring of immunizations for their children. Parents Caring about a child does not guarantee parents will be able to provide for that child adequately. Commitment to the welfare of that child does not ensure that the best health interests of that child/children will be met. Expectations expressed by health care -25- providers for a child are weighed by the parents in light of their perceptions. These perceptions are shaped by the totality of their past and present experience. Perceptions about the potential threat of illness to their child is weighed against the barriers and benefits encountered by initiating a particular health behavior. The Health Belief Model (Becker, 1974) is presented in this study as the organizing framework for understanding how these perceptions influence individual behavior. This potential conflict between provider/nurse expectations and parents perception of a situation indicate assistance may be needed which will facilitate an awareness of the health needs of their child/children and to help them carry out these responsibilities for the promotion of physical/mental well-being of the family. Studies concerning parental participation in the care of children has focused primarily on the role of the mother in decision making relative to the welfare of the child/children (Becker, Drachman 8 Kirscht, 1972; 1977; Graham, 1982). The literature is noticeably lacking in research directed at understanding the fathers participation in this responsibility. Stolz (1967), however, studied 39 families in which separate interviews with both the mother and father were taped, transcribed and coded. Almost all (922 of the mothers and 822 of the fathers) volunteered information about interaction with their spouses as an influence in the rearing of their children. Of those giving data about such interaction, 69% of the mothers and 922 of the fathers cited what they should do as a frequent occurrence. About two-thirds of the -26- parents stated that their discussions ended in mutual agreements. When disagreements did occur, the mother's opinion tended to prevail. Many statements of values the parents held for parenthood and childrearing were made and included (in order of emphasis); moral, family, interpersonal, emotional, security, education, orderly living, biological, play and economic. This study would lead one to believe both parents are contributing significantly to the decision making process concerning the care of children. Hughes (1980), however, states that mothers still face the burden of feeling continually and ultimately responsible for the health, development and happiness of their children. However much help a mother may get in bringing up her children, she is still likely to feel that she is the person beyond whom there is no recourse or appeal and who is answerable for whatever happens. The 1970's saw a movement of women out of the household and into the workplace. The result has been an intrapersonal conflict between the traditional expectations as mother/wife and those of employer/employee. Increasing obligations to family, home and work have placed greater emphasis on the role of the father as an active participant in caring for the home and children. The extent to which this is carried out is, of course, highly individualized and may, in fact, be far more theoretical than actual. In spite of this shift in spouse expectations and responsibilities and greater sharing of family and home obligations, it has not changed the fact that women continue to be the primary decision maker concerning the family's health related needs (Graham, 1982). -27- One is left to surmise what impact these increased demands upon a mother's time and resources means in terms of following an immunization schedule for her children; and whether her perceptions are "accurate" enough to initiate a positive action. Similarly, this change in roles assumes the father now (or has potential for doing so) plays a significant part in making these health-related decisions. Finally, one is left to wonder what his perceptions of acquiring immunizations for his children are and to what extent they match the mothers. Vaccines A vaccine is a type of antigen consisting of either living or dead organisms (Anderson, 1962). For the purpose of this study, the following vaccines only will be discussed. These vaccines are for those illnesses which are highly communicable and are common in childhood. They include measles, mumps, diphtheria, pertussis, tetanus, polio and rubella. Immunization Immunization is the process of administering vaccine. The basic series of immunizations as recommended by the American Academy of Pediatrics (AAP) includes the optimal basic series as four DPT (diphteria, pertussis, tetanus), three OPV (oral polio vaccine), one measles, one rubella and one mumps (MMR) vaccination following this schedule: -23- AGE VACCINE 2 months DTP, TOPV h months DTP, TOPV 6 months DTP 15 months Measles, Mumps, Rubella 18 months DTP, TOPV “-6 years DTP, TOPV This immunization schedule lends itself to noncompliance by the parents. Attending to it requires an availability of resources, be it time, trransportation, money, or a provider. Mothers - in particular the poor, the employed and those with more than one child (Peterson, 1969) - find it increasingly difficult to meet the demands brought about by this schedule while trying to attend to other commitments and obligations. Additionally, the perceived threat of a childhood disease may not be great enough to overcome the perceived barriers to acquiring those immunizations. The role fathers play in meeting this responsibility is unknown. Traditional role expectations have not included him in this aspect of child care. However, as parental role boundaries blur, it might be anticipated that fathers will become not only more aware of the immunization process but more actively involved in making the decision to immunize their child/children. The Preschool Child and Childhood Diseases Immunization programs have been most successful at immunizing children at the school age level (Peterson, 1979). This has been due, primarily, to individual state legislation now requiring documented proof of immunization against common childhood diseases upon entry to school. Excluded, however, are preschool children, for whom no law now ensures their immunization. Failure to immunize these children has resulted from the fact that, unlike the school age child, they are not a "captive" group. Additionally, preschool children are more at risk for the common childhood diseases and are, in fact, considered by many health officials to be a critical period for immunization (lmperato, 1977). It is for this reason the immunization schedule proposed by the American Academy of Pedatrics presents appropriate ages for initiation of immunization with specific spaced intervals for a vaccine series based upon optimum effectiveness (AAP, 197k). Certain groups of children, being "at risk" for complications from a vaccine itself, are excluded from immunizations. The American Academy of Pediatrics identifies these children as including those with 1) an acute febrile illness, 2) an active cerebral process, 3) failure to thrive, h) immunosuppressed children, 5) a "serious" reaction to a previous vaccination, or 6) those with specific long-term illness (198k). Legally, children may be exempted from immunization based upon parents religious convictions. -30- For purposes of this study, preschool children will include "normal" newborns (those not born with genetic defects, congenital malformations) and with no restriction placed on the number, sex, physical or mental conditions, of other children in the family. Childhood disease includes those vaccine-specific diseases presented previously. They include: diphtheria, pertussis, tetanus, polio, measles, rubella and mumps. In summary, children unable to make decisions concerning their own immunization status, must depend upon the parent(s) to accomplish this for him/her. The parent(s) develops and organize perceptions in terms of the internal and external factors (modifying factors, cues to action) influencing their daily lives. These perceptions, as the parent(s) individual representation of reality may or may not be an accurate interpretation of the situation. Additionally, perceptions of a mother and father may differ significantly and thus influence the final decision to act. Thus, the child is, in a sense, "at the mercy” of his/her parent(s). It is imperative, therefore, that health care providers intervene on the child's behalf to assist them, through their parent(s) to achieve optimum immunization levels. The HBM, as a framework, aids the health care provider in accurately assessing a parent(s) individual interpretation of childhood disease and vaccines. By understanding perceptions of susceptibility, severity, barriers and benefits, the health care provider can then selectively influence, alter and/or change a parent(s) perceptions/beliefs in order to achieve immunization for a child/children. .3]. Relation to Nursing Theory The goal of nursing is the absence of childhood communicable diseases in the preschool child through optimal immunization levels. The child, not responsible for seeking out his/her own health care, must rely upon the parent(s) to assist them in maintaining health. Therefore, the nurse interacts with the parent(s) in working toward the acquisition of immunizations for the child/children. Within this interaction, the Health Belief Model can be used as a framework for identifying and organizing perceptions relative to health behaviors. Kings' (1981) theory provides the framework within which the nurse, in clinical practice, interacts with the parent(s) to share information, knowledge and to set goals as a means for modifying health behavior (See Figure 2). Kings' (1981) theory involves five basic concepts. These include Man, the social system, perception, interpersonal relationships and health. It is from mans ability to carry out certain activities that the theory is derived. Thus, man has the ability to: 1) perceive (to develop his/her own awareness or interpretation of a situation), 2) think (perception and thinking help man to generalize, to discriminate and to identify relationships), 3) feel emotions, h) choose between alternative courses of action which are influences by perception, thoughts, and emotions, 5) set goals, 6) select means to achieve those goals, and 7) make decisions. ' ‘aam flip..- -32- PERCEPTIONS INFORMATION 4.. _______________ KNOWLEDGE I NURSE : .. MUTUAL BEHAVIORAL OUTCOME EVALUATION GOAL-SETTING GOAL ATTAMINMENT I INTERACTION —-—) TRANSACTION 4, OUTCOME I INTENT TO IMMUNIZATION ABSENCE OF IMMUNIZE DISEASE INTENT NO: I TO IMMUNIZE I II I PARENT(S) I OF PRESCHOOL I CHILD I Likelihood of I taking action ‘__ _____________ VS. Likelihood of 22; taking action Figure 2: Integration and schematic representation of the conceptual model. -33.. Man is able, therefore, to interpret, to organize and to transform information from his experience to memory, whereupon the composite of thoughts, feelings and attitudes represent his/her own unique image of reality. This image of reality is termed "perception” and from perceptions flow behavior. Three systems interact continuously. Individuals make up the personal system. When these individuals form groups they become interpersonal systems, e.g., the family. Groups with common interests, goals and values coming together form a social system. Man functions within these three systems through interpersonal relationship in terms of his or her own perceptions. It is within the interpersonal system that interaction between two or more persons takes place and here that each person brings to the situation his/her own knowledge, needs, goals, expectations, perceptions and past experiences which ultimately influence their behaviors within that interaction. While all behavior is communication, it is but a small part of the process. It is the ability to understand the meaning for behaviors by first, understanding the perceptions influencing it that makes up "good” communication (King, 1981). Communication, therefore, takes place in an atmosphere of mutual respect and a desire for understanding which is ultimately influenced by the interrelationships of a person's goals, needs and expectations. Both the nurse and parent bring with them their own individual perceptions of reality. Therefore, in trying to help parents cope with -3“- obligations and responsibilities, it is important that the nurse find a ”common ground” with the parent(s). This shared frame of reference between nurse and parent(s) consists of sharing facts, beliefs, expectations and preferences. This shared reality--perceptions--provides the basis of common understanding necessary for mutual goal-setting. The activity of mutual goal-setting involves helping parents to make decisions and to choose between alternatives. This decision making process requires information and is an interactive process going in two directions. That is, as the nurse shares information/knowledge with the parent(s), he/she, in turn shares concerns, problems and perceptions of the problem. Based upon this, the nurse assists the parent(s) in setting a goal for health behavior. To summarize, the interaction process involves the following underlying assumptions as represented by King (1981). They are: 1. Perceptions of the nurse and of the parent influence the interaction process. 2. Goals, needs, and values of the nurse and the parent influence the interaction process. 3. Individuals have a right to knowledge about themselves. A. Individuals have a right to participate in decisions that influence their lives, their health, their community and their families. 5. Nurses have a responsibility to share information that helps individuals make informed decisions about their health care. -35- 6. Individuals have a right to accept or to reject health care. 7. The goals of the nurse and of the parent(s) may be incongruous (p. ”3). Goal-attainment takes place in the transactional phase and, for purposes of this study, it is here the parent(s) acquires immunization for the child/children. Attainment (or lack of attainment) of the goal is a function of the quality of the interaction between the nurse and parent(s). Should the goal not be met, the nurse and parent(s) must return to the beginning of the interaction process to once again understand perceptions and behavior; and thereby develop the common frame of reference necessary to redefine the needs, goals, and strategies consistent with individual perceptions (see Figure 2). Finally, evaluation and the measurement of the effectiveness of care takes place in the outcome. For purposes of this study, effectiveness of care is the absence of those childhood communicable diseases previously identified. This, Kings' theory is selected as the basis for understanding the nursing process relative to the study problem. It is utilized as a mode for implementing nursing interventions where the aim of nursing is to assist the parent to take responsibility for those health-related behaviors directly affecting their child/children. Integration and Schematic Representation of Conceptual Models In summary, individual perceptions are influenced and shaped by many factors. Among them are demographic, developmental, knowledge and social-psychological variables. Additionally, general health -36- motivation, as an individual interest and control in ones own health is included. "Cues to action" also impact perceived threat and are instrumental as a critical incident which may propel an individual in a particular direction - either toward or away from a preventive health action. The perceived risk of contracting an illness is a subjective state 1 resulting from the interaction of individual perceptions and the modifying factors. This perceived threat may be high or low and is operant in deciding whether the perceived benefits of overcoming this threat are sufficient to take action. If it is believed that the benefits of taking an action significantly outweigh the barriers there is likelihood of taking an action i.e., immunization. Conversely, if the threat of illness is not perceived as being great enough (benefits do not outweigh the barriers) the individual is unlikely to take the preventive health action. Should benefits and barriers balance, the individual will probably vacillate back and forth between taking/not taking a health action until such time as a "cue" or critical incident occurs to tip the balance in either direction. Individual perceptions, beliefs and values are formed prior to entering the interaction phase (Figure 2), with the health care provider. The nurse, therefore, must understand that when the parent(s) enters this relationship they bring with them the totality of their own individual realities. It is, therefore, within the interaction phase that both the nurse and the parent develop a common, shared understanding for working toward a goal(s). The nurse and patient explore and agree upon the means by which specific health behaviors might be attained (mutual goal-setting) by exploring alternatives and making decisions concerning the means for achieving it. With the goal of immunization identified, the parent and the child move toward the transaction phase where goal-attainment takes place. The outcome of the model is the absence of those communicable diseases previously defined. The Health Belief Model, then, is a tool by which the nurse, at the point of interaction, is able to assess the parent in terms of their perceptions, and by knowing which components are below a level presumed necessary for behavior to occur can assess the likelihood the parent(s) will take action. Thus, interventions and strategies can be appropriately modified. Both Kings' theory and the Health Belief Model assume that change in behavior is possible. As perceptions are identified, steps can be taken to change them and as perceptions are alterable, so too, are behaviors. Summary In this chapter, the concepts and theories relevant to this study have been integrated into a conceptual framework. Presented in Chapter III is a review of the literature covering pertinent background related to the research problem. ) -33- Chapter III Review of Literature* Introduction The research questions posed in this study are concerned with the relationships between parents' (fathers) perceptions of their child's susceptibility to common childhood diseases, the severity of that disease if contracted by the child and the benefits and barriers to acquiring immunizations to protect their child from contracting such illnesses. The review of literature will include an overview of immunization practices and controversy surrounding the acquisition of immunizations, the likelihood of a parent's taking health action and the Health Belief Model as it describes a father's health care behavior for her child. Childhood Disease and Vaccines In 1980 the Public Health Service, Department of Health 8 Human Services issued a report entitled “Promoting Health/Preventing Disease: Objectives for the Nation." This report included the following immunization objectives to be achieved by 1990 for the United States. They are as follows: 1. ”Childhood immunization-improved services and protection. -At least 902 of children have their basic immunization series by age two. *In collaboration with Froemke (1985). -39- -At least 90% of children in day care centers and kindergarten through 12 are fully immunized. -Development of a national plan for mass immunization programs. 2. Childhood immunization-increased public and professional awareness. -All new mothers receive immunization instruction before leaving the hospital. 3. Childhood immunization-improved surveillance and evaluation. -At least 952 of all children through age 18 should have up-to-date official immunization records in a uniform format. -Surveillance systems that report at least 902 of those hospitalized and at least 50% of those not hospitalized with vaccine-preventable definitions" (Hinman 8 Jordan, l980, p. #38). The control or elimination of infectious disease has been a subject of great interest for many years. Of all the approaches to date, the most effective, and certainly the most feasible, has been that of stimulating active immunity by the inoculation of attenuated agents, inactivated whole organisms, or purified antigens. The goal for active immunization is the induction in susceptible individuals of an immunity resembling that found during convalescence from an infectious disease, but without the risk of the accompanying morbidity and mortality attributed to the naturally occurring disease. An ideal immunizing agent should be a) immunogenic, particularly in the age groups at greatest risk of infection or disease, b) well tolerated by those -40- immunized, without undue discomfort or disability, c) nontransmissable to others, d) free of early or late complications, e) nononcogenic, f) capable of quantity production with uniform characteristic, i) stable under conditions likely to be encountered prior to administration, j) inexpensive, and k) administered by a technique acceptable to those who are immunized (Hehrle 8 Wilkins, 1981). Hany currently available vaccines lack one or more of these criteria, yet have remained useful in providing at least some control of disease. Unfortunately, the deficiencies in individual vaccines have not always been detected during the initial trial of evaluation, but have often become apparent only after widespread administration. For example, reactions encountered among recipients of inactivated measles vaccine were seen after exposure to natural measles infection or attenuated measles virus months or even years after the vaccine had been administered. For other vaccines, like oral poliovirus vaccine, the occasional adverse effects among recipients with impaired resistance became more apparent and of greater concern with the decline in occurrence of this disease. Each disease presents unique problems. The benefit to be derived from immunization must be measured against the cost and resources needed to achieve the gain anticipated - the absence of childhood communicable disease. While all common childhood disease are included in this study, only those illnesses for which vaccines are now being debated will be included in the review of the literature in order to limit the scope of the problem. Therefore, immunizations for poliomyelitis, measles, and pertussis will be reviewed in this chapter. -41- Poliomyelitis has several prominent characteristics that have favored support for vaccine development and an acceptance of immunization by the public. First, the disease was highly visible and greatly feared. The paralysis, often extensive and permanent, along with the highly publicized respiratory cases drew more attention to this disease than to many other health problems. At this time, two vaccines for the prevention of the paralytic disease have been developed. Two approaches were utilized: lPV (inactivated polio vaccine) and DPV (oral polio vaccine), a live attenuated virus. The problem of a small but appreciable risk of paralysis among DPV recipients and unimmunized members of their families persists today and fuels the debate concerning these vaccines (Fedson, l979). Although inactivated polio vaccine (IPV) and trivalent oral polio vaccine (DPV) are both effective in preventing poliomyelitis, the Immunization Practices Advisory Committee (ACIP) of the Public Health Services has considered the benefits and risks of each vaccine to the entire population and has recommended DPV as the vaccine of choice for primary vaccination of children in the United States. Vaccine-associated poliomyelitis is a complication of the widespread use of DPV. In the period 1969 - 1980, I91.“ million doses of DPV were distributed in the United States, and 93 cases of vaccine-associated poliomyelitis were reported. Of the 93 cases, 36 occurred among vaccine recipients (l case per 8.1 million doses of vaccine distributed) and 57 among household or community contacts of vaccinees (1 case per 5.l million doses distributed). Host vaccinees -42- (92%) who acquired polio were less than or equal to h years of age, whereas most persons (73%) who acquired polio after contact with vaccinees were more or equal to 20 years of age (Wherle and Wilkins, 1981). Because of the overriding importance of ensuring complete immunity of children and because of the rarity of DPV-associated disease, the ACIP recommends that responsible adults be informed of the small risk of vaccine-associated poliomeylitis and that DPV be administered to a child regardless of the vaccination status of adults in the household (CDC, 1982, March 5). Sporadic imported cases continue to be reported along with the vaccine-associated cases, averaging nine cases per year. With declining incidence of the naturally acquired disease, it appears likely that vaccine-associated cases represent a problem that will hamper efforts at eradication of the disease. Localized outbreaks continue to occur among members of religious sects who have traditionally refused all vaccines (CDC, 1982, March 5). Heasles A safe, effective and stable vaccine providing lasting immunity offers the possibility of measles eradication. The introduction of the first live attenuated measles vaccine in 1963 and the subsequent widespread use of live further-attenuated measles vaccine since I965 substantially reduced the incidence of measles in the United States. Despite the promise of success in eradicating the disease, measles remains endemic in the U.S. and increased prevalence has been observed every three to five years since 1967 (CDC, 1982, April 16). The Center for Disease Control reported in 198“ that measles was up 8“: from the previous year with a total reported cases of 2,322. While these numbers remain significantly less than the half million per year in prevaccine days, this report comes two years after the federal governments target date for eliminating measles in the United States (”Heasles," 198A). The measles virus has persisted in communities with a large proportion of immunes. Past measures for control have relied primarily upon extensive use of vaccine in preschool and young, school-aged children and mass immunization programs when an increase in reported measles cases was recognized. Additional measures, such as school immunization laws and school exclusion, have been utilized to increase immunization coverage (Hiddaugh 8 Zyla, 1978). In recent years, the median age of reported cases has increased and more adolescent and young adult cases have been recorded (CDC, 1983, August 12). The inability to identify and successfully immunize those susceptible to measles in the U.S. has hindered attempts to eradicate the disease. These individuals were vaccinated between 1963 and 1967 with a vaccine of unknown type since their only vaccination may have been with inactivated vaccine. Since killed measles vaccines was not distributed in the U.S. after 1967, persons vaccinated after 1967 with a vaccine of lnknown type are not in need of revaccination (CDC, 1982, May 7). A recommendation to increase the age for routine measles immunization -uq- from 12 months to 15 months of age (Krugman, 1977) was based on indirect and direct evidence that small amounts of persistent maternally acquired measles antibody affect the seroconversion rates in infants 12 months of age (Hinman, 1979). It is unlikely that eradication of measles in the United States will be realized as long as substantial numbers of susceptibles remain. it has been estimated that in a population of 100,000, only 26 new cases are necessary to keep measles endemic (Black, et al., 1971). Currently in the United States, approximately 2h,000 cases are reported in endemic years (CDC, 1983 January 7). Amler, et ai. (1982) state that as long as measles incidence rates are 10 to 100 times higher outside the United States than within it, international importations will be potential sources of measles infection. Although relatively few imported cases are preventable, transmission has been limited when immunity levels are high (Turner, Amler, 5 Drenstein, 1982). Because indigenous measles is extremely rare in the United States, a major challenge exists to maintain high immunization levels. Measles and other preventable diseases will return if the imperative to vaccinate children is relaxed and immunization levels allowed to fall (Kirby, 1982). The cornerstone of the measles elimination program is the achievement of high immunization levels, with requirements for all children fundamental for success. Past studies have demonstrated that states with such regulations have the lowest incidence rates for -45- measles and that enforcement of these regulations with exclusion of noncompliant students correlates best with low measles incidence (Hiddaugh s Zyla, 1978). Pertussis Immunization in infancy is recommended because of the severe complications and high mortality associated with pertussis in early life. Five to 20 persons die each year and the incidence of the disease has been reduced to 1,000 - 2,000 cases per year. The vaccine has a high frequency of transient, nondamaging side effects, a lesser frequency of potentially serious adverse effects, and a remote risk of permanent neurological sequelae or death (Baraff, et al., 1984). In a double-blind study conducted by Baraff, Cody and Cherry (198A), the rates of minor and short-term reactions following DPT (vs. DT) immunization were high. Local reactions occurred in 642 of DPT recipients and minor systemic reactions (fever, drowsiness, fitfullness, vomiting, anorexia, persistent/fretful crying) occurred in 50%. Children who received DT immunization experience less frequent and less severe reactions. Convulsions and hypotonic/hyporesponsive episodes each occurred in 1:1,750 immunizations. No evidence of encephalopathy or permanent brain damage was seen in any vaccine recipient. Little discussion has taken place concerning these adverse reactions until recently. Quite the opposite is true, however, in Europe. -h6- In Great Britain over the last 8 years, there has been an extensive debate in the public media and in professional circles over the risks and benefits of routine infant immunization against whooping cough. The media picked up on the controversy, keeping cases of children with brain damage, alleged to have been caused by vaccine, before the public. Pictures of children with immunization-induced brain damage were shown on television. In the late 1970's immunization rates dropped dramatically throughout the country, resulting in whooping cough developing into an epidemic far beyond anything experienced in over 20 years (Williams 5 Dajda, 1980). As late as 1982, pertussis vaccination was still being contested in Great Britain with an alarming rise in the incidence of whooping cough. From 1977 to 1979, 102,500 cases of the disease were reported in the United Kingdom resulting in a total of 36 deaths. Account must be taken, however, that many children suffered prolonged and sometimes severe illnesses with sequelae. It has been estimated that during the epidemic in England and Wales, when some 5,000 children were admitted to hospitals (2,000 cases under 6 months of age), 50 children required admission to intensive care units, 200 developed pneumonia, and 83 had convulsions induced by the disease. These figures do not include the many cases of severe and complicated illnesses in children who were cared for at home. The late effects of these illnesses are unknown, but evidence supports that some may continue to have persisting after-effects (Miller, Alderslade 8 Ross, 1982). Kanai's (1980) extensive investigation reveals similar difficulties in Japan where the incidence of whooping cough had undergone large changes in the past 30 years. During this time, the nation-wide vaccination against whooping cough had been carried out with concomitant improvement of vaccination procedure. With improvement of vaccine quality and vaccination procedure the incidence of whooping cough declined to a low of 393 reported cases and no fatalities in 197“. Because of the low incidence of disease, neurotoxic reactions to pertussis vaccine gained notice and spurred much discussion of the benefit-risk ratio of the vaccine. In Japan, at this time, Public Health authorities must deal with the decline in public acceptance of vaccination resulting from the publicity created by mass communication networks as well as by the Association of Parents of Vaccine Damaged Children (Kanai, 1980). Miller, et al. (1982) states that, at present, it is not clear whether the concern expressed about the side effects of pertussis vaccine in different countries reflects true variation in the incidence and nature of the problem or whether the vaccines used vary in toxicity. The British Department of Health and Social Security has attempted to gather such information with only partial success due to poorly kept records (Miller, et al., 1982). The controversy concerning pertussis vaccine side-effects has escalated in the United States. In March of 1979, the Tennessee State Department of Public health reported four deaths in infants aged 2 to 3 Inonths who had received, within 2“ hours of their deaths, a dose of DPT -h8- vaccine from a single lot. Oral polio from multiple lots had been given at the same time. Further investigations of infant death in Tennessee from August 1977 through March 1978 and August 1978 through March 1979 indicated 8 cases of infant death in the 1978 to 1979 time period and two deaths in the 1977 to 1978 period, within one week of vaccination (CDC, 1979, March 19). Further update on the controversy surrounding infant deaths, however, indicates that countries where immunizations with pertussis antigen-containing vaccines are started at six months of age, the age distribution of infant deaths is the same as reported in the United States (CDC, 1985, March 17). The Federal Center for Disease Control reported that in 198“ 2,400 cases of whooping cough were reported. It is estimated that perhaps 10 times this number actually suffered from the disease but were never reported. Thirteen of the 1,339 infants under 6 months of age who contracted whooping cough died (Engleburg, 198k). lmperato (1977) states that "public apathy has historically been neutralized by panic reactions to outbreaks and epidemics, resulting in increased numbers of immunizations” (p. 1972). Relatively safe and effective vaccines exist to immunize children against the common communicable disease. In spite of this, immunization levels in the United States continue to be less than optimum. This has been due largely to the apathy, not only in the public, but health care community as well. it is an apathy generated by the relatively low incidence of these diseases brought about by the vaccines themselves. Consequently, large pools of susceptible children have been left VWJlnerable to outbreaks of these illnesses. There is no medication or vaccine that does not have the potential at some time, under the proper set of circumstances, to cause some reaction in a given individual. The majority of vaccine-related reactions, however, are mild and self-limited. The more severe reactions can be reduced to a minimal incidence by adhering to the immunization guidelines and excluding those from whom there are medical complications. The risks from immunizing children are far less with pertussis vaccine as well as other vaccines than those inherent in their acQuiring any of the vaccine preventable diseases. Parents organizations, U.S. drug companies manufacturing biologicals, as well as the government have entered into the controversy surrounding mass immunization programs, sanctions (school entrance requirements), and ultimate responsibility for potentially serious side effects. It would appear that what the health care profession considers medically expedient, the public, in part, now views as both medically unacceptable and socially unnecessary. Due to the success of previous immunization campaigns and low incidence of communicable diseases in the general population an apathetic and, at times, resistant individual whose child is in a good state of health to accept what can be an uncomfortable and occassionally hazardous procedure. The challenge for health care providers is the maintenance of adequate immunization levels in the midst of this growing apathy in the United States. There is a need, therefore, to identify and describe parental perceptions as they influence health care decisions and immunization-seeking behavior. T Health Belief Model as it Describes Preventive Health Behavior Hochbaum, Leventhal, Kegeles, and Rosenstock (1966) developed the Health Belief Model in an effort to explain preventive health behavior. Since its development, the Health Belief Model has served as a framework for a significant number of studies relating to preventive health behavior (Rosenstock, 197A), illness behavior (Kirscht, 197k), sick role behavior (Becker, 197A), and chronic illness behavior (Kasl, 197k). To have a perception of susceptibility or severity to a disease one must have knowledge of a disease/illness and its' potential medical consequences. Further, it proposed that a particular action would be beneficial by either reducing susceptibility to, or severity of the disease. Also, barriers should not outweigh the perceived benefits of the health action. Some cue to action (either internal or external) is believed to be necessary to trigger the individual to want to achieve the desired health behavior. Later modification of the Health Belief Hodel included addition of the notion of general health motivation (Becker 8 Haiman, 1975) and an ability to alter the perceptions and beliefs that make up the model (Kegeles, 1969, Kirscht 8 Haefner, 1973). Rosenstock (197%), states that a patient will not comply with a health regimen unless he exhibits the following set of characteristics: 1) health motivation, 2) perceived susceptibility to a particular illness, 3) perceived severity, h) perceived benefits of intervention, 5) perceived barriers to taking an action and 6) knowledge of the medical condition and the prescribed regimen (1975). Perceived severity implies that the patient believes a future occurrence of a given illness would have a serious impact on his life, or an existing illness state, if left untreated, would have an undesirable impact. Perceived barriers to action means that the patient believes the cost (social, financial) of the recommended action is outweighed by the perceived benefits. Likelihood of Parents Taking Health Action Relatively low levels of public participation in preventive health programs have been documented in the literature (Hingson, 197k; Prather, 197k). Additionally, poor rates of compliance with prescribed regimens for medical care have been identified (Marston, 1970; Dracup, 1982), and specifically with immunization schedule (Hingson, 197k; Peterson, 1979)- The literature is extensive related to discovering and understanding the determinants of voluntary health-related actions. These studies range from the medical (Anderson, 1968), economic (Muller, 1965), demographic (Anderson, 1973; Markland 8 Durand, 1977), organizational (Becker, et al., 197“), geographic (Collver, et al., 1967; Marks, et al., 1979), social (Langlie, 1977); and personal and motivational (Becker, et al., 1972). In the last 15 years there exist a number of eclectic reviews of research which summarize findings across all or most of the previous perspectives. -52- Investigators have attempted to determine what differences exist between families who have their children immunized against common childhood disease and those who do not. A prospective study done over a one-year time period in Kentucky (n - #87), was designed to assess the effectiveness of notices urging DPT and polio immunizations; and to show characteristics of families that had not begun immunization of their child/children by an acceptable time after birth. The investigation indicated that parents of inadequately immunized children had lower incomes, more children, and were less likely to visit a physician for any reason (Martin, Fleming, Fleming 8 Scott, 1969). There was no statistically significant difference between the results of immunization and those who did not receive notices. This would tend to indicate that sending out notices to parents as a "cue to take action" (acquiring immunization) does not result in increased immunization levels, but that more research is required involving different populations. The major limitation to this study was a sample drawn from an all white population. Thus, its ability to be generalized is limited. In an effort to improve the immunization delivery system in Hissouri, a statewide study of the sociopsychological factors effecting infant immunizations was undertaken (Markland 8 Durand, 1976). A mail survey was conducted of the parents of all two year olds (n . 19,000) to determine the child's immunization status. From this population, a random sample of #27 parents was drawn. The test instrument used asked information concerning the child's immunization history, demographic, -53- socioeconomic and ”psychological” factors, and parents' exposure to the media. Initial statistical analysis of the data used a simple descriptive approach with a 95% confidence level. The results of the study revealed the following profiles for the adequately and inadequately immunized. Adequately immunized children had parents with a higher perception of disease seriousness and risk of disease, higher age levels, higher education levels, smaller families, greater media exposure, and showed a greater proportion of white children. The parents of children who were inadequately immunized had a low perception of disease seriousness and risk of disease. These parents were also younger, had a lower education level, had larger families, less media exposure and smaller prOportion of white children. These study results are hardly surprising, however, the profiles are based on general samples. A comparison was done by geographic location throughout the state and several subgroups were identified with differing demographic variables. Education and unemployment of rural mothers was not a demographic concern but was with urban mothers. There was no breakdown differentiation identified for fathers. A weakness of the study was a lack of explanation of the measurement for risk of disease and disease seriousness (Markland 8 Durand, 1976). In Ohio, over a one month period, a population for study was selected from all children born to married parents. From this base a 10% random sample consisting of 1,003, 2 year old children was selected in order to identify those factors associated with failure to receive the recommended vaccinations. Parental education, family size and -Sh- maternal age were compared with the completion rate for the basic immunization series. Several factors were found to be related to lower levels of immunizations. Children who received their vaccinations from private doctors had a better vaccination rate than those who attended clinics run by the Public Health Department. A child having one parent with less than 12 years of education or having three or more siblings had a forty times greater risk of failure to complete his immunization series than a child who's parents are both college graduates, or had less than three siblings (p - .01). Rural populations had less response rate to obtaining immunizations than did urban populations (Marks, Halpin, Ervin, Johnson, 8 Keller, 1979). Results further revealed that when socioeconomics were controlled, the association with race no longer holds; that is, no differences in completion rate are found between white and non-white children in the same socioeconomic level. However, an overall effect of socioeconomics remains with higher rates of completion in the higher socioeconomic level" (Marks, et al., 1979, pg. 306). Although a large sample size, this study was done over a relatively short period of time and included only married families, therefore limiting its ability to be generalized. This differs with the Markland and Durand study which found that white children were more likely than non-white children to be adequately immunized. Ferguson, Harwood, and Shannon (1983) sampled attitudes of mothers (n - 1123) to a series of issues relating to compulsory protection of children. The issues examined were: the introduction of -55- car seat restraint legislation, compulsory fencing of domestic swimming pools, preventive health care linked to family benefit and desirability of water fluoridation. Included in Family Benefit payment was the suggestion that ”to ensure all children are immunized and receive routine checkups, that these procedures be linked to the Family Benefit payment so that Family Benefit is not paid unless the parents produce evidence that the child has been immunized, etc." (pg. 338). Approximately 90% of respondents favored car restraints and fencing around swimming pools, 60 to 702 favored health care linked to Family Benefit (p 0.05), but less than one-half were in favor of water fluoridation. There were slight but nontheless statistically significant tendencies for maternal attitudes of the issues explored to vary with family social background and the age of the mothers. Results of this investigation support the introduction of compulsory methods for protecting a child's health. Its generalization is limited, however, due to its use of a New Zealand population in which questions were linked to a Family Benefit (insurance) payment. In a more recent study in England (Burney 8 Cook, 1983), 197 mothers were interviewed before discharge from the hospital to ascertain their initial intentions about vaccination of their children. The mothers studied went either to their general practitioner or to a Public Health Center to have follow-up care and their babies vaccinated. -55- On follow-up nine months later, 154 mothers were interviewed, 92% of the infants had received at least one polio, diphtheria and tetanus vaccine. Eighty-five percent had received at least one vaccine against whooping cough, 19 mothers had been advised against the vaccine by either Public Health Officials or their physician. Failure to have their children vaccinated against whooping cough correlated with the mother's initial intention, although a high proportion of mothers who were initially against the vaccine started vaccination by the 9-month followbup time (1983). Results of the study showed that mothers attending general practitioners were more likely to have their children vaccinated against whooping cough than those attending public health clinics. It should be pointed out that during this time in England the use of whooping cough vaccine was controversial. The mother's initial intention to use whooping cough vaccine was less than for other immunizations. The services used, however, also played an important part and those attending their general practitioners were likely to have their babies vaccinated regardless of their initial intentions. In summary, one's ability to predict the likelihood of taking a positive health action (immunization) is largely influenced by the recognition of a common "parent-profile" as gleaned from a review of the literature. Thus, those parents most likely to have their child/children immunized are more educated, with high socioeconomic level, older, married with smaller families, white, urban and more likely to receive immunizations through a private physician. The Health Belief Model and Father's Preventive Behavior Researchers, after many years of neglect, are finally taking an interest in fathers. The father is (and always was) an integral member of the family system but his role in that system has undergone many changes in the last century. In the past, his function has been better defined than it is now because the roles of the mother and father have traditionally been more delineated. The father saw his role influenced by many things; the male role he was cast in as a child, the expectations both of family members and society, as well as the protector and provider of the family unit (Cronenwett, 1982; Jeffecoate, 1979; Kiernan 8 Scoloveno, 1977). Changes in the father's role as economic provider in the family may be directly related to the changing function of the family in a society undergoing rapid economic and social changes (Cronenwett, 1982; Kirnan 8 Scoloveno, 1977). With more mothers being required to enter the work force to provide for the family's basic needs, the role of the contemporary American father has changed. The role of the mother, as she joins the work force and becomes economically independent has been better defined, but the father is still found struggling for his identity within the family. Jeffecoate (1979) looked at perceived role of the father and found that although both parents felt a father should share in the caregiving tasks for a child, both mothers and fathers regarded "looking after the baby" primarily as the mother's role and not the fathers. The father was still placed in the traditional role of being provider and protector. "The Woman's Movement has succeeded in changing general societal beliefs, so that today it is less important to differentiate male and female social roles. Fathers find they must redefine their roles in light of this changing society" (Kirnan 8 Scoloveno, 1977, p. #86). This is, at best, a challenge to fathers to do away with patriarchal roles and stereotypes, thereby becoming more responsive to the increasingly complex needs of the family unit. Men today are expressing an increased desire for a more active parenting role. Araji (1977) presented findings that suggest more fathers are helping with the child care role, possibly in response to mothers working outside the home. In spite of this, however, substantial numbers of husbands and wives were experiencing role attitude-behavior incongruence in the performance of family roles. Araji (1977) attempted to show that attitudes of mothers and fathers toward family roles were egalitarian. Overall this was true but, in response to child care roles, fathers and mothers indicated that wives should perform the majority of the role requirements. "Thus, the general conclusion is that where role attitude-behavior incongruence exists (as in child care roles), both married men and women express egalitarian role attitudes but this egalitarianism is not generally reflected in role behaviors” (p. 309). As of yet, society has not provided a clear father-role that includes the broader range of verbal interaction, caregiving or emotional involvement and nurturance. Therefore, the man who is placed in the dual role of being an active father while remaining in the work force encounters a high degree of role conflict (Cronenwett 8 Kunst-Wilson, 1981). In a research study done to explore father's experience in the pre- and post-partum period, Fein (1976) selected middle-income couples (n - 30) who were expecting their first child. Three major variables were examined; dependence, marital sharing, and anxiety. Data were gathered by both questionnaire and interview format. Fathers expressed varied feelings as evidenced by responses such as having no idea how much work was required to care for a baby. Nineteen fathers reported having regular infant care responsibilities but, 29 reported that they participated in less than half the baby care. A major finding was that developing a pattern of role activities and expectations was important both to individual fathers and the couple. "Couples who agreed on the ways they would share and divide basic family tasks seemed to have an easier time coping” (Fein, 1976, p. 56). It was found that fathers in the study adopted one of two roles; that of breadwinner, responsible for earning money or, of equally sharing most infant care with their wives (Fein, 1976). Fathers have only recently begun to acquire equal status with mothers as objects of interest for research. Studies have been done on infant caretaking (Erickson, et al, 1979; Jones, 1981; Manion, 1977; Wandersman, 1980), father-infant interaction (Katsh, 1981; Lamb, 1977), and attitudes about parental and maternal roles in childrearing (Araji, 1977). Most studies have focused around the father in the hospital setting or soon after coming home with the new baby. Little is known about long-term participation of the fathers. For purposes of this -50- research study, a more in depth review of the literature will focus on studies done only on fathers and their participation in infant caregiving. A study undertaken by Manion in 1977 was designed to measure the fathers' participation in caregiving behavior and his newborn child. A questionnaire was given to fathers (n - #5) in the hospital and again at six-weeks post-partum. The questionnaire was designed to gather information on how many times in the previous week had the father fed, bathed, rocked, washed or diapered the baby. Percentages of time were calculated from responses to categories of none, 1 to 2, and 3 or more (Manion, 1977)- Results of the study showed that the number of participating fathers decreased as the complexity of the task increased. Ninety-two point three percent of the fathers participated in rocking to comfort the baby while only 18 percent participated in giving the baby a bath. It was found that fewer than one-third of fathers provided more than just occasional caretaking for their six-week-old infants. Limitations of the Manion (1977) study were the small sample size and use of a convenience sample to gather data. The study would be strengthened if it had been conducted over a longer period of time. In a study by Wandersman (1980), #7 first time fathers were selected from participants in expectant parent education classes who were asked to respond to a questionnaire when their new baby was 2 to 3, 5 to 6, and 9 to 10 months of age. Fathers were divided into two -61- groups. Twenty fathers attended Family Development Parenting Groups with their wives and infants. The remaining 27 fathers had expressed an interest in attending the parenting class but did not enroll. Fathers were asked to respond to questions on frequency of participation in baby care (feeding, bathing, and diapering). Fathers reported being more comfortable in their roles as the baby grew older, but indicated no increased skill in caring for their baby. "These findings may be due to the fact that the mean level of father participants increased over the first 10 months from between 'never' and 'sometimes' to between 'sometimes' and 'often.‘ Few fathers reported 'daily' or 'frequently during the day' participation in baby care" (Wandersman, 1980, p. 160). The investigator found that participating in a parenting group did little to alter the pattern of adjustment for fathers with a newborn child but that fathers were positive in their verbal reports related to the benefits of sharing their concerns with other parents In the group. Again, the ability to generalize the results of this study is limited. The sample size was small and chosen on the basis of convenience. There was, however, an ability to compare two groups of fathers responses to the same questions. Utilizing a questionnaire format, Jones (1981) studied father- infant dyads (n - 51) at 28-72 hours of age and at one month of age to determine the effects of early contact, sex and irritability of the infant on fathers' perceptions, interaction, caretaking and play. The dyads were sampled from families who infants were delivered at a local -52- hospital The infants were all first born, full-term, normal vaginal deliveries. Questions on caregiving measured the frequency in the previous three days of fathers playing, bathing, feeding, changing clothes, and holding and/or rocking his infant when crying. The results of the study indicated that early contact between fathers and infants appears to enhance nonverbal communication at one month but had no effect on caregiving or play. Fathers had more positive perceptions of low irritability daughters and high irritability sons; they engaged in caretaking activities more with one month old infants identified as highly irritable at 28-72 hours. Irritability is positively related ( p ( .05) to frequency of feeding the infants. That is, fathers fed the high irritability infants more frequently than the low irritability infants (Jones, 1981). A limitation to this study was the use of a convenience sample to gather research data. A second limitation to the study was the use of the Broussard Neonatal Perception Inventory with a test-retest reliability of .22 when used with first time mothers over a 20-2h hour period. The previous studies reviewed make apparent that fathers are involved, somewhat, in the caregiving tasks of their newborn children at an early age. It is reasonable to assume that some of these learned behaviors will follow through as the infant gets older. Some of these relationships can be applied to participation in child care which might include taking the child for well child checks or sickness-related health care. One study done on caregiving tasks indicated that fathers participation decreased with complexity of task (Manion, 1977). Making an appointment ahead of time, dressing and then transporting a young child to a health care facility is a much more complex task than rocking, feeding, or diapering an infant. Research must continue to observe caretaking tasks over an extended period of time. If participation does continue to decrease with complexity of tasks it is reasonable to assume, then, that the father would participate even less in health seeking behavior activities. The Health Belief Model (Becker, et al., 1975) was utilized in a study designed to identify the psychological factors associated with the voluntary cooperation of mothers and fathers in mass genetic testing. An attempt was made to determine the impact on participation of screening and motivation to have additional children, perceived likelihood of carrying the Tay-Sachs gene, and perceived severity of the impact of learning that one is a carrier. The other indicator of health motivation measured was that of typical health behavior. The desire (for both fathers and mothers) to have (additional) children was highly related to program participation. "There was no significant difference in participation according to the second motivational measure used, which included frequency with which one thinks about health, an assessment of present health as being good, the probability of going to a physician immediately when illness occurs, and recency of last visit to physician” (Becker, et al., 1975, p. 6). This best illustrates how an individual's views about his own health ~6h- are more likely to be associated with behavior undertaken to protect himself, than with actions taken to protect unborn, future children. No other studies done utilizing the dimensions of the Health Belief Model study new fathers or fathers in the childbearing years and with the specific intent to look at health seeking or maintaining behavior for the child. An extensive review of (more current literature) reveals no research which looks specifically at fathers input into the decision-making process of acquiring health care, or more specifically for purposes of this study, the acquisition of immunization for the children. The present research is an attempt to understand the potentially significant role fathers can play in the health care of their children by providing them with an opportunity to share their thoughts and attitudes about the health of their child apart from the mother. As the trend continues to involve fathers in the more traditional role of childrearing such as rocking and diapering, it is reasonable to assume that this will expand to include more complex tasks such as seeking health care for the child. It is as important to understand fathers perceptions of common childhood disease and vaccine as it is to understand the mothers and this knowledge should be utilized to promote joint decision making. In summary, significant gaps were noted in the literature. No studies could be found related to a fathers involvement in health care related decisions for a child. The previously mentioned studies -65- present the following information; fathers play a significant part in the care of their children particularily as traditional roles are undergoing change. Investigators have focused on father-infant bonding, sex stereotyping, caregiving and individual task accomplishments. Although not directly applicable to the scope of the present research, these studies reviewed lend support to the important role fathers play in the development of their child. Fathers may not be given the opportunity to be as involved as they want to be in the lives of their children due to socialization of males in American society. Modifying and Motivational Factors Langlie (1977) explored the relationships of preventive health behavior to several modifying and motivational variables, including socioeconomic status, cosmopolitan versus parochial orientation, ability to control one's life versus a belief in the power of external forces and beliefs in the value of health. Langlie (1977) agreed with Rosenstock's (197k) hypothesis that the preventive Health Belief Model would have greater applicability to middle-class individuals who exhibit goal-oriented, future-directed behavior, than to low-income individuals who supposedly opt for immediate gratification. A random sample of the adult population of Rockford, Illinois were questioned by mail with a 622 return rate of 383 subjects. Preventive health behaviors measured by Langlie included driving habits, smoking, exercise, nutrition and preventive medical and dental check-ups. -66- Perceived susceptibility, benefits, and barriers were measured. Severity was excluded due to earlier failure to prove its significance in studies of preventive health behavior. Langlie's (1977) findings were generally consistent with the predictions based on previous work with the preventive Health Belief Model in terms of sociodemographic data. Individuals who engaged in preventive health behavior tended to be of high socioeconomic status, to interact frequently with others, to have positive attitudes towards health care providers, to believe they could control their own lives and to be older and female. Conversely, those who exhibited few signs of engaging in preventive health behavior tended to originate from the parochial group and were low income. Langlie (1977), unlike Rosenstock (197k), found no substantiation for the belief that high perceived susceptibility led to increased preventive health behavior. Both Rosenstock (197k) and Langlie (1977) conclude that the person of low-income and/or ethnic origin is less likely to engage in preventive health behavior than the middle-class white. Bullough (197A) hypothesized that the low income individual faced social alienation/isolation which translated itself into feeling of powerlessness and hopelessness, with subsequent psychological barriers, either real or imagined; and which ultimately hindered preventive health care behavior. Bullough (1972) further asserts that poverty is negatively related to utilization of health care and may be better explained by this concept of social isolation. While ethnic -57- minorities, poverty and social isolation do not have direct implications for the present research, it does lend credence to the aspect of sociodemographic and other modifying factors. The concept of "cues to action" as a significant modifying factor became evident in an earlier prospective study by Kirscht et al. (1966) which analyzed beliefs and behaviors of 1,500 persons followed by a repeat survey of 589 persons 15 months later. Data were collected on cancer, tuberculosis, tooth decay and gum disease from a stratified multi-stage probability sample of adults in 70 geographic areas of the U.S. Personal interviews were conducted and information gathered on toothbrushing behavior over the past day, dental visits over three years, preventive medical check-ups over five years, and tuberculosis and cancer screening over 10 years. Complete data were gathered on only 297 persons. Those individuals who took one preventive action were found to be likely to engage in another preventive health care behavior. However, there were no significant correlations between susceptibility, severity or benefits and the four types of preventive action. The subjects were also compared for actions in relation to sociodemographic factors. It was found that those persons with higher income, education, and job status were more likely to undertake preventive actions, even relatively inexpensive ones such as toothbrushing. Kirscht et al. (1966) noted the similarity of these findings to those of other studies and concluded that more than knowledge and an ability to pay are included in preventive health behavior. Persons at varying socioeconomic levels possess different socially defined views of what is appropriate behavior, and that these views determine what action they will manifest. Rosenstock (197k) went on to hypothesize that the lack of correlation between the Health Belief Model variables and actions as manifest in the Kirscht et al. (1966) study may have been related to the absence of a direct stimulus to take preventive action. Previous studies cited some incentives to seek preventive care as accessibility (Hochbaum, 1958) or prepaid health plans (Kegeles, 1963). In contrast, Kirscht et al. (1966) nationwide sample had not been exposed to intensive health teaching nor was free or easily accessible health resources offered. Thus, Rosenstock (197k) concluded that "cues to action" at the time of the earlier studies may have been a significant variable which affected behavior. Two more studies lend further support to the general explanatory model of health behavior. Haefner and Kirscht (197D) attempted experimentally to increase readiness to follow preventive health practices by presenting communications about selected health probiems. These messages were intended to increase both perceived susceptibility and/or severity regarding the health problems, and beliefs in the efficacy of professionally recommended behavior. Significantly more persons exposed to such messages visited a physician for a check-up (in the absence of symptoms) in the eight months after the experimental manipulation than in a control group not exposed to the messages. -69- Fear arousal attempts to influence the person's perception of severity has only been effective in changing behavior in certain circumstances and then, only for a short period of time. It was assumed that if a person thought his/her disease was serious, he/she would be more likely to do something about it. However, fear arousal may immobilze the individual or incite denial. Alternately, a minimal amount of fear arousal may not be enough to motivate. Moderate fear arousal often appears to be the most effective, but fear messages must be accompanied by a specific action recommendation that the individual can take to reduce his fear (Becker 8 Maiman, 1975). Personal sense of control over a situation is identified in Becker's et al. (1977) study of mothers of obese children which tested the efficacy of two levels of fear-arousing communications in enhancing regimen compliance. Subjects were randomly assigned to one of three groups: receipt of "high fear" (booklet), receipt of a ”low-fear" message (booklet) with similar (but less threatening) information and receipt of usual care (control group). Fear arousal interventions were found to be significantly associated with weight loss. (Further analyses, however, demonstrated that when the effects of interventions were controlled, the HBM variables continued to significantly predict weight change.) Leventhal, et al. (1965) have concluded that once a person has reached some subjective threshold of fearfulness, it is doubtful that any attempt to increase perceived severity will lead to further acceptance of health recommendations. In a more recent work, the Health Belief Model was adapted to measure compliance with an insulin-dependent diabetic regimen. The thirty subjects were comprised of male and female patients between 18 and 73, with 80% of the subjects being over the age of 50. The subjects were interviewed in their homes to obtain data about the patient's compliance levels, health beliefs, as well as demographic data. "Three items were used to measure each of the five aspects of the Health Belief Model (perceived susceptibility, perceived severity, and perceived benefits and perceived barriers to acquiring health care and cues to action)" (Cerkoney 8 Hart, 1980, pg. 395). Responses to each item were made on a five-point Likert scale, where subjects indicated their degree of agreement with the statement. Maximum score possible on the measurement tool was 61 with this group's scores ranging from 36 to 55. Cues to action included in the study were adherence to diet, using diabetic exchange lists, foot care (both by observation and self- report), carrying a source of sugar, ablility to describe the signs and symptoms of hypoglycemia and the wearing of a diabetic identification band. There was found to be a correlation between health beliefs and compliance with this group of subjects. Those subjects who perceived their disease to be serious, and responded to cues, were more compliant with their diabetic regimen than those subjects who neither perceived their disease to be serious nor responded to cues (Cerkoney 8 Hart, 1980). In this same study "cues to action" were found to be the aspect of the Health Belief Model that had the highest correlation with health seeking behaviors. Susceptibility, severity, treatment benefits and barriers had a correlation of 0.5 or better when measured against a composite of the level of health belief. The ability to generalize these findings is limited due to the use of a small, non-random group of subjects, the retrospective nature of the study, and the arbitrary doubling of the compliance scores obtained by investigator observation. In summary, other factors have been found to influence preventive health behavior. Correlations between the Health Belief Model dimensions and actions may be related to other modifying variables which ultimately provide the motivation to take action. Some of these factors include a preventive health orientation as defined by one's ethnic group and/or socioeconomic status. Additionally, a direct stimulus may be necessary to take action. Such a stimulus, or "cue," may include overt messages (postcards, telephone calls, media) which change one's perception of susceptibility and/or severity and thus providing the incentive to take an action. Summary Due to the effectiveness of past immunization campaigns, an apathetic public has developed which has not been confronted with the side effects of potentially serious communicable disease in their children. This problem has been amplified by the recent spate of popular press releases related to the potentially serious side effects -72- of vaccines. Subsequent moral and legal issues have been raised both by parents and politicians. In this chapter, studies have been reviewed in an attempt to understand a parent's perception of preventive health measures. The HBM has been reviewed as a tool whereby one might understand and thereby predict parents' preventive health behavior related to their children. Janz and Becker (198k) state that ”despite the impressive body of findings linking HBM dimensions to health actions, it is important to remember that the HBM is a psychosocial model; as such, it is limited to accounting for as much of the variance in individuals' health-related behaviors as can be explained by their attitudes and beliefs" (Janz 8 Becker, 1984, p. 45). In summary, as presented in the literature, investigators have studied, almost exclusively, mothers preventive health care behavior for themselves and/or their family. No research has been found which addresses a father's preventive health behavior in relation to his children. Additionally, no research has been found related to the comparison of mothers and fathers perceptions of vaccines and immunizations. The major limitation of the HBM at this time is the lack of standardized scale development and scoring for each dimension. Additionally, no particular intervention strategies for altering these dimensions has been done. Chapter IV METHODOLOGY* Overview In this research, an attempt is made to describe similarities and differences in parental perceptions (mothers vs. fathers) concerning childhood disease and vaccines, and to identify their intent to acquire immunizations for their children. Parents' perceptions of their child's susceptibility to specific illnesses, perceptions of the severity of that illness, belief in the benefits of preventive health services, and general health motivations along with "cues to action” are the study variables derived from the preventive Health Belief Model (Becker, et al., 1977). Potential modifying variables such as age, education level, income, ethnicity, and number of children are assessed on a self-report demographical questionnaire. The techniques for analysis of the data include both descriptive and correlational statistics. The purpose of this chapter is to present the methodology and procedures utilized in this research study. The sample, setting, data collection procedure with human rights protection, development of an instrument, scoring techniques and procedures for data analysis are discussed. *This chapter is written in collaboration with Froemke (1985). Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis -7h- Hypotheses There is a positive relationship between a father's perception of susceptibility to common childhood disease and the intent to acquire immunizations for a child. There is a positive relationship between a father's perceptions of the severity of common childhood disease and the intent to acquire immunizations for a child. There is a positive relationship between a father's perceptions of benefits of a vaccine and the intent to acquire immunizations for a child. There is an inverse relationship between a father's perception of the barriers to immunization and the intent to acquire immunizations for a child. There is a positive relationship between mothers' perceptions of susceptibility to common childhood disease and fathers' perceptions of susceptibility to common childhood disease. There is a positive relationship between mothers' perceptions of severity of common childhood diseases and fathers' perceptions of severity of common childhood diseases. Hypothesis VII: There is a positive relationship between mothers' perceptions of benefits of a vaccine and fathers' perceptions of benefits of a vaccine. Hypothesis VIII: There is a positive relationship between a mothers' perception of the barriers to immunization and fathers' perception of the barriers to immunization. Sample The study participants were a time sample of 50 sets of parents drawn from all parents having just delivered an infant on the post-partum unit and who voluntarily agreed to complete study questionnaires. Questionnaires were administered and collected over a five-week time period (1 March to 6 April, 1985). The following were the criteria for selection: 1. Both parents (the biological father and mother) agreed to complete and return the questionnaire. 2. Both parents must share the same household. 3. Both parents must be age 18 or over. A. Both parents must be able to read and write English. 5. The newborn infant would be "normal" i.e., no genetic defects or congenital malformations. Because the sample was voluntary and not the result of random section, the results of this study can be generalized only to new parents possessing characteristics which are like those of the sample. Results should not be considered to be representative of all new parents. -76- Data Collection Site A single site, located in a midwestern urban area with a population of approximately 250,000, was utilized in obtaining subjects for this study. One hundred study participants (50 sets of parents) were obtained from the post-partum unit of a 240-bed, acute care hospital. Approval and written permission were obtained from the hospital research committee (Appendix A) to allow patients to be contacted by the researchers. Data Collection Procedure The investigators ascertained the appropriateness of parents for inclusion in the study according to the previously listed selection criteria (Appendix B). It was explained to the parents that in an effort to better understand parents' beliefs about the health of their child, two graduates students (Heidi Froemke, R.N., and Lyn O'Connor, R.N.) from the Michigan State University College of Nursing were conducting a study. It was further explained that involvement in the study would require that both parents be given separate questionnaires that would take approximately 15 minutes of their time to complete. Those expressing interest were given two blank envelopes each containing a questionnaire (Appendix D) and an explanatory letter (Appendix C). Additionally, a consent form was provided for those parents who expressed a willingness to be contacted by telephone in 2 to 6 months time for follow-up (Appendix E). Because of the limited time available for data collection, mothers were approached for inclusion in the study by the investigators. Questionnaires were left for both the mother and father with instructions for completion. Mothers were informed that should the father elect pp; to participate, both questionnaires should be returned unanswered. Parents were assured that their names and all information on the questionnaire would be kept confidential. Parents were also informed that becoming a participant in the study would not change the medical treatment they were receiving and that they might withdraw from the study at any time. Those deciding not to take part in the study were thanked for their time and consideration. Parents had the opportunity to discuss, with the investigators, their participation in the study. For those parents deciding to participate, it was stressed that completion of both questionnaires (mother's and father's) was essential and that questionnaires should be filled out independently with no discussion of individual responses taking place. Parents were informed that the investigators would return every other day to collect completed questionnaire and to answer questions. Questionnaires not collected by the investigators were given to staff nurses by parents to be placed in a box on the unit. A total of 83 children were born during the time in which data was being collected. Sixteen sets of parents were eliminated because they did not fit selection criteria. Thirteen sets of parents were approached by the investigators but declined participation in the study. Four sets of parents were missed due to early discharge. The length of stay for new mothers ranged from one to seven days. Verbal consent to participate in the study was received from 166 parents. Of those who consented to participate, 100 parents returned completed questionnaires. Of those who returned questionnaires, 27 signed consent forms to be contacted by telephone in two to six months. Consent forms returned for the purpose of follow-up were retained by the investigators for future research. Development of the Instrument The instrument used was a modification of the preventive Health Belief Model by Becker, et al. (1977). The original questionnaire was developed to be used in an interview situation with mothers of newly diagnosed obese children. Questions covered five subscales reflecting susceptibility, severity, benefits, barriers, and modifying factors. Alpha coefficients for the Health Belief Model subscales employed in the study were above .90 for the category of perceived susceptibility and perceived severity, over .80 for perceived benefits, .70 for general health motivation and over .50 for perceived barriers. The low coefficient for barriers was felt by the original investigators to be the effect of individuals having to make an immediate assessment about a jpgggg problem/event, resulting in a lower internal consistency. Subsequent studies, using further modifications of the Health Belief Model and perceptions to barriers and asking individuals to make an assessment of a problem in "here and now," have been shown to have higher coefficients (Becker, 198A; Cerkoney 8 Hart, 1980). The modified instrument, utilized by the present researchers, contains items adapted from the original questionnaire of Becker et al. (1977), after consultation with Marshall Becker and a review of the literature. The present instrument contains 50 items which measure each of the major perceptual subscales. In an effort to develop questions relevant to the study population, alternative questions for the subscale of barriers were asked. Also included were sociodemographic questions. The scale was placed on a four response alternative Likert-type format. The major perceptual variables are: perceived susceptibility to a disease (11 items), perceived severity of all illness (11 items), perceived benefits of preventive health measure (11 items), perceived barriers of preventive health measures (8 items), general health motivations (h items) and "cues to action” (5 items). Potential modifying factors are assessed through collection of sociodemographic data and are used to characterize the nature of the obtained sample. All questions were positively worded to avoid participant confusion. Operational Definitions of the Study Variables In order to describe parental perceptions regarding the health of their child, a modification of the Health Belief Model questionnaire developed by Becker et al. (1977) was used (Appendix 0). Parents' responses were assessed by summing items on a questionnaire designed to look specifically at the following categories: -30- Perceived Susceptibiligy Perceived susceptibility is the subjective risk of contracting an illness or condition. parents' perceptions of their child's susceptibility to specific illnesses were evaluated by 11 questions. Specifically, these questions include numbers 20, 21, 28, 29, 30, 31, 32, #2, A3, 53, 5h. Perceived Severity Perceived severity is the degree of worry created by the thought of a disease as well as by the kinds of difficulties an individual believes a given health condition will create for them and/or the medical/clinical consequences of a health problem. Parental perceptions of the severity of specific illnesses or conditions were evaluated by responses to questions 22, 26, 27, 33, 3h, 36, 37, 38, 41, #8, 58. Perceived Benefits Perceived benefits is the belief that a given action will be effective in reducing the threat of a disease. Belief of parents in the benefit of preventive health measures are evaluated by responses to questions 35, 39, “0, “h, “5, “9, 50, 51, 52, 56, 57- Perceived Barriers Perceived barriers is the belief that an action itself may be inconvenient, expensive, unpleasant, painful or upsetting, resulting in avoidance. Perceptions of parents of the barriers to obtaining preventive measures were evaluated by responses to questions #6, A7, 55, S9, 61, 62, 63, 6h. -81- General Health Motivations General health motivation states that frank motives towards good health do exist. Such motivations are evaluated by responses to questions 23, 2h, 25, 65. "Cues to Action” "Cues to action” are those critical incidents which propel or motivate an individual to take an action or preventive health behavior. "Cues to action" are evaluated by responses to questions 16, 17, 18, 19, 66. Modifying_Factors Modifying factors are those sociodemographic, developmental and general background questions which characterize the nature of the sample. Modifying factors are identified by parents' responses to questions 1, 2, 3, A, 5, 6, 7, 8, 9, 10, 11, 12, 13, 1h. Intent to Acquire The intent to acquire is a positive or negative indication about one's intentions to have a child immunized and is measured by parents' responses to question 67 and 68. Scoring Responses to each question were given a numerical score. An arbitrary point value from 1 to h was assigned to each variable's response format: strongly disagree (1 point); disagree (2 points); agree (3 points); and strongly agree (h points). Parents' perceptions of susceptibility, severity, benefits, barriers, and general health -32- motivations were operationally defined as high or low on the basis of total score for each subscale created by summing individual items. Total point values for each category ranging from high to law were: perceptions of susceptibility (11 to #4 points); perceptions of severity (21 to AA points); perceptions of benefits (11 to Ah) points; perceptions of barriers (8 to 32 points); and general health motivations (A to 16 points). Parents' perceptions were operationally defined as high or low on the basis of mean scores obtained for each subscale. "Cues to action” and modifying factors were not placed on a Likert format and were, thus, analyzed descriptively. Intent to acquire was scored by responses to a yes/no question. Pretest of Instrument A total of eight individuals who did not participate in the study critiqued the instrument at several stages of its development for readability and clarity of instructions and questions. A subsequent pilot study of eight sets of parents indicated that sample selection, procedure and instrument required no revisions. The study was conducted utilizing the format presented in this chapter. Statistical Analysis of Data Sociodemographic/economic data and information regarding family size, immunization status of other children and other background information were analyzed using descriptive statistics. The range, mean and percentages, along with tables summarizing frequencies of sociodemographic categories and other related factors are presented in Chapter V. Because all hypotheses in this study consisted of statements of hypothesized correlations between study variables, a correlation matrix was constructed to correlate each of the Health Belief subscales. The level of significance was set at .05 for the Pearson Product Moment Correlation. In addition, the following interpretation of the Pearson Coefficients computed between study variables was utilized for deciding the clinical importance of any statistically significant findings: 0.00 - 0.20 no relationship 0.20 - 0.35 slight relationship 0.35 - 0.65 moderate relationship 0.65 - 0.85 marked relationship 0.85 - 1.00 high relationship (Borg and Gail, 1979) Mothers' responses were compared to fathers' res onses utilizin P 9 paired t-tests. Protection of Human Rights Specific procedures were followed to assure the rights of study participants were not violated. Approval of the human rights protection procedures was granted by the Michigan State University Human Subjects Review Committee on February 6, 1985 (Appendix D). On January 2“, 1985, approval for clinical investigation was granted by the site hospital's Human Subjects Committee (Appendix A). An attempt -3u- was made by the investigators to contact physicians of those patients qualifying for inclusion in the study for the purpose of explaining the research study. An explanation of the research study and goals, the approximate time involved in participation, the nature of the questions to be encountered and assurances of anonymity were provided each participant as part of the letter of explanation (Appendix C). Number-coded questionnaires were separated from patient-identifying data upon receipt by the investigators and all data were transcribed in aggregate form for computer analysis. Study Division The first four chapters of this investigative study have been written in collaboration with Froemke (1985). Chapter V and VI are written separately. Froemke presents an analysis of the data and implications related to mother's responses to questionnaire items. O'Connor (1985) presents an analysis of the data and implications for fathers' responses to questionnaire items. Both investigators, jointly, will include in Chapter V and VI an analysis of the correlations between mothers' and fathers' responses to study variables as identified by the study hypothesis. -85- Summary A discussion of the methodology utilized in this study was presented in Chapter IV. A detailed discussion of the sample, collection site, questionnaire, human rights protection, procedures, and statistical analysis strategy was presented. In Chapter V, the sample will be described. The reliabilities obtained for the Health Belief instrument will be presented. Values obtained for study variables and correlations between variables will be presented in relation to Specific hypotheses. -86- CHAPTER V DESCRIPTIVE ANALYSIS OF DATA Introduction In the first section of this chapter, the descriptive findings of the sociodemographic data found in this sample will be discussed. A discussion of reliability of the Health Belief Model instrument for each of the major study subscales of susceptibility, severity, benefits, barriers and general health motivation will be included. The analysis of the data obtained for each subscale will be presented in relationship to the hypotheses of this study. Study Sample This sample consisted of 50 sets of parents having recently delivered a seemingly well child at the postpartum unit of a local hospital. Data were collected from the fathers through the use of a 70-item questionnaire before the child (and mother) was discharged from the hospital. Study subjects used in this investigation include all fathers who met the selection criteria (see Appendix B). Mothers used in the investigation by Froemke (1985) were selected in the same manner. Sociodemographic The fathers ranged in age from 21 to 38 years. The mean age was 29.2. Distribution of subjects according to age is presented in Table 1 . Forty-six of the fathers (92%) were white, one (22) was black, and two (0%) were Mexican American. One father (22) checked the category marked "other" but did not specify the ethnic background. TABLE 1 AGE DISTRIBUTION OF FATHER (n - 50) Age Range N Percent 21-25 10 20 26-30 22 4h 31'35 11 22 36-38 _1 4" TOTAL 50 100 The subjects were asked where they lived. Distribution of location is presented in Table 2. TABLE 2 DISTRIBUTION OF SUBJECTS BY AREA OF RESIDENCE (n I 50) Area N Percent Urban 26 52 Suburban 10 20 Rural 1“ 28 TOTAL 50 100 -33- Forty-seven (962) of the sample was married while three (62) were single, but currently living in the same household with the mother (see Table 3). TABLE 3 DISTRIBUTION OF FATHERS MARITAL STATUS Marital Status N Percent Married #7 98 Single _3 __6 TOTAL 50 100 The education level of the subjects ranged from "some high school" (82) to "postgraduate work" (122). No respondents indicated that they had "8th grade or less" years of education. The mean educational level of participants was between "some college" and "completed college." Distribution of subjects according to educational level is presented in Table 5. The income range for the subjects was 0 to $A0,000 or more annually. The median reported income range was $30,000 to $39,000. Distribution of annual income for subjects is presented in Table 5. TABLE ‘1 DISTRIBUTION OF FATHERS EDUCATION (n - 50) Education N Percent Some high school A 8 Completed high school 12 2“ Some college 13 26 Completed college 15 30 Postgraduate/professional _6 ._EE TOTAL 50 100 TABLE 5 PARENTS COMBINED ANNUAL HOUSEHOLD INCOME (n 8 50) Income N Percent 5 0 ' $ 9,999 8 16 $10,000 - $19,999 5 10 $20,000 - $29,999 12 2% $30,000 - $39,999 16 32 $40,000 or more _2 _18 TOTAL 50 100 -90- Modifying Factors The factors were asked to report the number of other children they had. The subjects responses ranged in number from no children (#02) to 5 children (12). The 30 fathers that reported having other children were asked to indicate whether these older children had received any immunizations. Twenty-nine of the respondents (972) reported "yes,” while one (32) repoted “no." Of the twenty-nine who answered "yes," twenty-five (8A2) stated their child/children had received DPT and MMR as having been given. Twenty-three (772) identified Polio as having been given. Seven (232) received those immunizations from the Public Health Department, twenty-two (782) from a private physician and one father (32) gave no response. Cues to Action Fathers were asked to indicate what sources of influence they utilize concerning the health care of their child/children. The following were cited: Twelve (82) said the nurse, 39 (2A2) said the doctor, 2“ (1A2) said family and friends, 36 (2A2) said the spouse, 32 (262) said themselves with no one citing books or magazines as an influence. When asked which one 323$ influences their decisions concerning the health care of their child 26 (522) stated the physician. No fathers indicated the nurse as the source of most influence. Ten fathers (202) stated they had received information regarding immunizations this hospitalization. Thirty-eight (762) answered they had not. Two (A2) gave no response. The fathers were also asked if they had recently read in magazines, books or newspapers, or heard over the radio or television, any information about immunizations. Twenty-four (A82) fathers responded ”yes" and 25 fathers (502) replied ”no." One father gave no response (22). The fathers were asked if the information they read was “for" or "against" immunizations. Seventeen fathers indicated the information was ”for" immunizations while 8 fathers indicated it was ”against” immunizations. Twentyefive fathers did not respond to the question. Open-ended Questions The age at which father's stated children should first be immunized ranged from one to 12 months with a mean age of A months and mode of 2.0 months. When fathers were asked to state why they would have their children immunized at the ages, reasons given were grouped by the investigator according to the similarity of responses. Six major response categories were found. Reasons for giving immunizations at these times were as follows: ”I don't know" 82 (n - A), "whenever the doctor says" 282 (n - 1A), ”based on baby's weight” 22 (n - 1), "as soon as possible” A2 (n - 2), ”because it's best for baby” 162 (n - 8), and because of what I've read“ 22 (n - 1). Forty percent (n - 20) did not respond. When fathers were asked to share suggestions as to how health care providers might best help parents get immunizations for their children the following responses were given. Two fathers (A2) felt the consequences of Egg immunizing a child should be better explained to parents. Five fathers (102) wanted immunizations offered free. One -92- father (22) wanted immunizations made a requirement by state law. Four fathers (82) felt more education should be provided new parents while still in the hospital. Eight (162) indicated that more publicity would be helpful and three (62) wanted immunizations provided in a way that was more easily accessible for parents. Twenty-seven fathers (5A2) did not respond to the question. In summary, fathers tend to be white, married, well-educated, and have a higher sociodeonomic status, living primarily in an urban area. Additionally, family size was small, with the majority of these other children having received their immunizations through a private physician. A majority of fathers cited themselves, their physician, or their spouse as the source of influence they utilize concerning decisions regarding health care for their child/children. Fathers were evenly divided in response when asked if they had read or heard over radio or television information regarding immunization. In response to a question asking at what age to to begin immunization, fathers gave responses in age ranging from 1-12 months. Also given were a variety of reasons for why their child should begin immunization at that age. Questions asking for suggestions as to how health care providers might best help parents get immunized also brought a variety of responses. -93 .- Dependent Measure-Intent to Acquire Immunization* Fathers were asked to state whether or not they planned to have their child immunized. Forty-nine fathers (982) stated "yes" while one father (22) was "undecided." No fathers responded "no.” Additionally, a second indicator was selected in order to predict the probability that a father would actually carry through on his intent to immunize. Fathers were asked to state at what age they would begin immunizing their child. For the present research, two months of age as identified by the American Academy of Pediatrics was selected as the "correct" response. Ages other than two months were considered to be "incorrect.” Analysis on this variable is included later in this chapter and shows that while fathers have "good” intentions they may have insufficient knowledge to carry through with the recommended immunization schedule. Health Belief Model The Health Belief Model was used as the organizing framework for this investigation. Parental perceptions regarding the health of their child were assessed by summing items on a questionnaire to look specifically at the following categories: perceived susceptibility, severity, benefits, barriers, and general health motivation. *Written in collaboration with Froemke (1985). -94- General health motivation states that frank motives toward good health do exist and may ultimately influence one's health care behavior. Therefore, while general motivation Is not included as a part of the research hypotheses, it was measured on a subscale similar to the other Health Belief Model dimensions. Factor Analysis of Health Belief Model Subscales Varimax factor analysis was utilized in an attempt to identify unidimensional concepts for the subscales of Susceptibility, Severity, Benefits, Barriers, and General Health Motivation. Factor analysis of the instrument items was found to be 225 unidimensional, that is few items fell out into the five original subscales as proposed by Becker (1977). Instead, factor analysis identified 1A different dimensions. Confirmatory factoring was not done. Additionally, Becker's (1977) original subscales were not reflected in the factors produced by the analysis. For purposes of this study the investigators will proceed with the analysis on the assumption that Becker (1977) developed the subscales theoretically. Becker's (1977) report of the analysis of data did not include an explanation of factor analysis of the subscales, further supporting the assumption that the scales were developed theoretically. Reliability of the Health Belief Model Instrument The realiability of the instrument was measured by computing coefficient alpha, which is an indication of homogeneity or internal consistency and estimates the extent to which different subparts of an instrument are equivalent in terms of measuring the critical attributes (Polit 8 Hungler, 1978). The subscales of the Health Belief Model were evaluated individually for internal consistency; perceived susceptibility, perceived severity, perceived benefits, perceived barriers and general health motivation. The initial analysis revealed a trend toward homogeneity among the item responses. That is, the responses tended to cluster under two of the four possible categories with only a moderate spread over the whole spectrum of possibilities. Only moderately reliable scales could be constructed (see Table 6). TABLE 6 RELIABILITY COEFFICIENT ALPHAS FOR THE HEALTH BELIEF MODEL SUBSCALES Scale Alpha Item 2 Actual Range No. of Items Susceptibility .88 3.06 2A-3A 11 Severity .82 3.01 27-A7 11 Benefits .78 2.A6 11-35 11 Barriers .A5 1.0A 2-12 6 GHM .52 2.95 5-12 3 The subscale of best reliability was "susceptibility” with a coefficient alpha of .88. That subscale having the least reliability was "barriers” with a coefficient alpha of .AS. One item (Appendix D) was eliminated from the subscale of General Health Motivation to yield an alpha coefficient of .52 for fathers. Alpha coefficients for barriers were extremely low. Because of the low reliability of the subscale for barriers the scale will be eliminated from further discussion in this chapter, the General Health Motivation subscale was retained for further discussion. Scale intercorrelations were subsequently corrected for reliabilities following deletion of these items from the instrument. TABLE 7 RANGE, MEAN, MODE 8 5.0. OF HBM SUBSCALES FOR FATHERS Subscales Actual Range X Mode S.D. Susceptibility 2A - AA 33.7 35 A.07 Severity 27 - “7 36.16 35 4-02 Benefits 11 - 35 27.1A 26 A.19 Barriers 7 - 12 8.5 8 0.9 General Health Motivation 5 - 12 8.8 8.5 1.3 -97- Correlation Matrix In general, the subscales were not correlated with each other, however, they did correlate moderately with the total score with the exception of barriers. This moderate correlation with the total was due to the subscale being included as a part of the total score. The correlation matrix indicates that a score on the one subscale tended to reflect the total. TABLE 8 CORRELATION MATRIX FOR SUSCEPTIBILITY, SEVERITY, BENEFITS AND GENERAL HEALTH MOTIVATIONS Susceptibility Severity Benefits GHM Susceptibility 1.00 Severity .A86* 1.00 Benefits -.286* .028 1.00 GHM .22A .270 .102 1.00 TOTAL .5A6* .796* .A62* .A80* *Statistically significant (-‘(.05) A statistically significant correlation was found between susceptibility and severity. Responses to the severity subscale (.A86) predicted 252 of the variation of response to the susceptibility subscale. This correlation is high enough that the two dimensions are very likely measuring the same concept rather than individual concepts. The statistically significant correlation between susceptibility and benefits (-.286) indicates a negative relationship. Ten percent of the variability of benefits can be predicted inversely by response to the susceptibility subscale. Presentation of the Data Related to the Research Hypotheses In this section, descriptive and inferential statistics are presented as related to the individual research hypotheses. Hypothesis I: There is a positive relationship between fathers perceptions of susceptibility to childhood disease and the intent to acquire immunizations for a child. Hypothesis II: There is a positive relationship between fathers perceptions of the severity of common childhood illness and the intent to acquire immunizations for a child. Hypothesis III: There is a positive relationship between fathers perceptions of the benefits of childhood immunizations and vaccines and the intent to acquire immunizations for a child. Because the question concerning the intent to acquire immunizations produced no variation in response, it was not possible to utilize Pearson Product Moment Correlations. Therefore, responses to the Health Belief Model dimension of perceived susceptibility, severity, and benefits, could not be shown to have a relationship to intent to acquire. Comparison of Mothers and Fathers In collaboration with Froemke (1985) the following descriptive analysis of both mothers and fathers is provided in relationship to sociodemographic descriptors, modifying factors and the research hypotheses, the dimension of CHM and the correct vs. incorrect age. Sociodemographic Descriptors The age of study mothers ranged from 19 to 37 years with a mean age of 27.A years. Fathers ranged in age from 21 to 38 years with a mean of 29.2 years. Ninety percent (n - A5) of the mothers were white compared to 922 (n - A6) of the fathers. The remaining 102 of the mothers and 82 of the fathers were distributed fairly evenly across the five other race categories. Education for both mothers and fathers was distributed across five categories. Two percent (n - 1) of mothers and 82 (n - A) of fathers had not finished high school. Thirty-two percent (n e 18) of mothers and 262 (n - 13) of fathers had completed some college. Twenty percent (n - 10) of mothers and 302 (n - 15) of fathers had finished college while 102 (n - 5) of mothers and 122 (n - 6) of fathers had postgraduate or professional education. Income did not differ between mothers and fathers as the question asked for household, not individual, income. Thirty mothers and 30 fathers reported having other children with the number of children reported differing slightly. This was probably due to prior marriages with subsequent reconstituted families. Mean number of children for mothers was 1.1 and for fathers 1.8. In response to the question concerning previous immunizations for these -100- other children 972 (n - 29) of both mothers and fathers stated these other children had immunizations. All (n - 25) of the mothers and 862 (n - 25) of the fathers reported DPT as having been given, 962 (n - 28) of mothers and 7A2 (n - 23) of fathers reported oral polio administration. Ninety-six percent (n - 28) of mothers and 852 (n - 25) of fathers reported MMR administration. Seventeen percent (n - 5) of mothers and 102 (n - 3) of fathers reported other immunizations which included BCG and TB tine tests. While mothers reported slightly more immunizations than fathers it was found to be statistically not significant. When parents were asked to identify ghggg their other child/ children had received their immunizations the following answers were elicited: 652 (n - 19) of the mothers and 7A2 (n - 22) of the fathers identified the private physician, 302 (n - 9) of the mothers and 232 (n - 7) of the fathers stated the Public Health Department. Only 52 (n - 1) of the mothers and 32 of the fathers checked "other." Parents were asked to check all of the sources of influence that helped them make decisions concerning their child's health care. The following information was elicited: 162 (n - 8) of the mothers and 2A2 (n - 12) of the fathers cited the nurse, 7A2 (n e 37) of the mothers and 782 (n - 39) of the fathers indicated the physician, A22 (n - 21) of the mothers and A82 (n - 2A) of the fathers cited family and friends as the source. Seventy-four percent (n - 37) of the mothers and 722 (n - 36) of the fathers indicated the spouse, 182 (n - 9) of the I101- mothers and 102 (n I 5) of the fathers cited magazines or books while 802 (n I A0) of the mothers and 6A2 (n I 32) of the fathers cited themselves as the source of Influence. Seventy percent (n I 35) of mothers and A82 (n I 2A) of fathers had read books, magazines, newspapers or heard over radio or television, information concerning immunization. Of these, A02 (n I 1A) of the mothers and 332 (n I 8) of the fathers stated that this information had been "against” immunization. Twenty percent (n I 10) of the mothers and 202 (n I 10) of fathers stated they had received information regarding immunizations during this hospitalization. When asked if they intended to have this baby immunized 962 (n I A8) of the mothers and 982 (n I A9) of the fathers said "yes." Four percent (n I 2) of the mothers and 22 (n I 1) of the fathers stated they were "undecided" about having this child immunized. The age at which mothers stated children should first be immunized ranged from one to 6 months with a mean age of 2.76 months and mode of 2.0 months. Fathers cited ages ranging from 1 to 12 months with a mean age of A months and mode of 2 months. Reasons for giving immunizations at these times were as follows: Eight percent (n I A) of mothers and 82 (n I A) of fathers stated "I don't know," 362 (n I 18) of mothers and 282 (n I IA) of fathers stated "whenever the doctor says," 22 (n I 1) of mothers and A2 (n I 2) of fathers stated "as soon as possible," 302 (n I 15) of mothers and 162 (n I 8) of fathers stated I102- TABLE 9 DISTRIBUTION OF MOTHERS AND FATHERS REASONS FOR IMMUNIZING AT SPECIFIC AGES Mothers* Fathers* N 2 N 2 I Don't Know A 8 A 8 When Doctor Says 18 36 1A 28 As Soon As Possible 1 2 2 A Because it's best for baby 15 30 8 16 Because of Information Read 3 6 1 2 No Response 9 18 21 A2 *Parents could provide more than one response. "because it's best for baby,” and 62 (n I 3) of mothers and 22 (n I 1) of fathers stated “because of information I've read." Sixteen percent (n I 8) of mothers and A02 (n I 20) of fathers did not respond. Those parents who were ”undecided" about having their baby immunized all stated that it was because of news articles they read and fear of bad reactions. When parents were asked to share suggestion as to how health care providers could help parents get immunizations for their children the following responses were given: 1A2 (n I 7) of the mothers and A2 (n I 2) of the fathers felt the consequences of pp; immunizing a child should be better explained to parents. None of the mothers, but 162 (n I 8) of the fathers were in favor of more -103- publicity. Four percent (n I 2) of the mothers and 102 (n I 5) of the fathers wanted immunizations to be offered free of charge to parents. Four percent (n I 2) of the mothers and 22 (n I 1) of the fathers wanted immunizations to be made required by state law. Fourteen percent (n I 7) of the mothers and 82 (n I A) of the fathers felt that more education should be provided while parents were in the hospital. Four percent (n I 2) of the mothers and 62 (n I 3) of the fathers wanted immunizations provided in a way that was more easily accessible for parents. Sixty percent (n I 30) of mothers and 5A2 (n I 27) of fathers did not respond. In Table 10, mean scores for fathers and mothers responses for each of the HBM subscales are presented. In addition, t-tests as a test of significance between group means are identified. Although a level of statistical significance was not reached as a result of a lack of variability in both fathers and mothers responses. Both fathers and mothers, however, tended to score similarly for each of the dimensions. In summary, no sociodemographic differences were found between mothers and fathers. Fathers tended to have more children than mothers. Fathers reported slightly fewer immunizations for these children than mothers. Hypothesis V: There is a positive relationship between mothers perceptions of susceptibility to childhood disease and fathers perceptions of susceptibility to common childhood disease. IlOA- TABLE 10 T-TESTS ON MATERNAL vs. PATERNAL REPSONSES TO THE HEALTH BELIEF MODEL ‘_ Mothers ‘_ Fathers Subscale X S.D. X 5.0. T-Test* Susceptibility 33.7 3.6 33-7 A.l .03 (II-AA) Severity 36.6 3.7 36.2 A.0 -.56 (ll-AA) Benefits 27.0 5.1 27.1 A.2 .11 (ll-AA) General Health Mot. 9.3 1.3 8.8 1.3 .067 (3-12) *All tests not significant. Eleven items were utilized in the analysis of perceived susceptibility. Each item could be scored from 1 to A, rendering a total possible score from 11 to AA for each mothers and father (see Table 7). For mothers the mean score for susceptibility was 33.7 and for fathers 33.7. Fathers and mothers tended to respond similarly based on mean scores alone. Therefore, the hypothesis can be neither accepted nor rejected. -105- Hypothesis VI: There is a positive relationship between mothers perceptions of severity of childhood disease and fathers perceptions of severity to common childhood disease. Eleven items were utilized in the analysis of perceived severity. Each item could be scored from 1 to A, rendering a total possible score from 11 to AA for each mother and father (see Table 7). For mothers the mean score for severity was 36.6 and for fathers 36.2. Mothers and fathers tended to respond similarly based on mean scores alone. Therefore, the hypothesis can be neither accepted nor rejected. Hypothesis VII: There is a positive relationship between mothers perceptions of benefits for childhood immunizations and vaccines and fathers perceptions of childhood immunizations and vaccines. Eleven items were utilized in the analysis of perceived benefits. Each item could be scored from 1 to A, rendering a total possible score from 11 to AA for each mother and father (see Table 7). For mothers the mean score for benefits was 27.0 and for fathers 22.1. Mothers and fathers tended to resond similarly on mean scores alone. Therefore, the hypothesis can be neither accepted nor rejected. General Health Motivation The alpha coefficient for fathers' general health motivation was low (.A6). In an effort to be consistent with the presentation of the data for fathers, item number 65 (see Appendix D) was deleted and a new coefficient of .52 obtained based on three items. As for ”barriers" -106- the scale was collapsed from a A to 2 response format - "agree" and ”disagree." "Three items were utilized in the analysis of general health motivation. Each item could be scored from 1 to A, rendering a total possible score from 3 to 12 for each mother and father (see Table 98. For mothers, the mean score for CHM was 9.3 and for fathers 8.8 (t I -1.86, p I .07). Although not statistically significant, a trend was found indicating that mothers had a slightly higher perception of general health motivation than fathers" (Froemke, 1985, p. 98). Correct vs IncorrectyAgg Although correlations could not be accomplished due to the lack of variability on the response concerning intent to acquire immunizations, an additional question concerning age at which immunizations should be started revealed a wide range of responses from 1 to 12 months of age. Twenty percent (n I 10) of the mothers and 102 (n I 5) of the fathers stated the correct age of 2 months. Fourteen percent (n I 7) of the mothers and 122 (n I 6) of the fathers stated incorrect ages ranging from 1 - 12 months. Sixty-six percent (n - 33) Of the mothers and 782 (n I 39) of the fathers did not respond to the question concerning age. Response to correct age vs. incorrect age was correlated with those parents already having other children and those for whom this child was their first. Twenty-seven percent (n I 8) of those mothers having other children gave the correct age of two months and 102 (n I 2) of first-time mothers gave the correct age. Thirteen percent (n I A) of those father having other children gave the correct response -107- while 52 (n I I) of first-time fathers stated the correct age. Although no statistical significance was found between first-time and other parents and the statement of correct age, a pattern is observed which has further implications for the present research. Seventy percent (n - 35) of the mothers and A82 (n I 2A) of the fathers had read or heard information concerning immunizations. Of these parents, 222 (n I 13) who stated the correct age had read information. Only 52 (n I 2) of those who failed to read any information gave the correct age. Those parents who read information were more accurate in identifying the correct age to begin imunizations (p ( .05). No statistically significant level would be reached when correct vs. incorrect age was correlated with the individual Health Belief Model dimensions of perceived susceptibility, severity, benefits, and barriers. Summar In Chapter V, data were presented which describe the characteristics of the sample, modifying factors and cues to action. Data were presented concerning each of the three hypotheses related to fathers perceptions of susceptibility, severity, benefits, barriers and general health motivation, and were analyzed with both descriptive and inferential statistics. The reliability of the instrument was evaluated using the Coefficient Alpha. In addition, demographic variables modifying factors and cues to action were presented comparing -108- mothers and fathers. Data were presented concerning each of the three hypotheses comparing mothers and fathers. No significant results were found for any of the six hypotheses. An overall summary of the research study and findings is presented in Chapter VI. -109- CHAPTER VI SUMMARY AND IMPLICATIONS Overview The purpose of conducting this study was to examine fathers perceptions of susceptibility to and severity of common childhood diseases, perceptions of benefits to and barriers to obtaining health care, and the correlation of those perceptions to fathers' intent to acquire immunization against these illnesses for his new born child. The study sample consisted of fifty new fathers who agreed to complete and return the questionnaire. Selected sociodemographic characteristics were obtained from the fathers for the purpose of describing the sample. Intervening variable data were obtained to be able to compare intent to acquire with fathers actual knowledge about immunization. Another purpose for the collection of this data was to be able to compare this study with the results of a study done by Froemke (1985). This researcher developed eight hypotheses. Four of the hypotheses were used to test for a positive correlation between fathers perceptions of susceptibility to and severity of common childhood diseases and the benefits and barriers to acquiring health care to prevent the diseases, and their intent to acquire immunization for their newborn child. The remaining four hypotheses were used to compare fathers perceptions of susceptibility, severity, benefits, barriers and intent to acquire immunization with mothers perceptions of susceptibility, severity, benefits, barriers and intent to acquire immunization. -110- Chapter V1 is organized into several sections. First the sociodemographic characteristics of the sample will be described. A discussion of these findings as they relate to other researchers' results will be done. The research hypotheses are presented along with a possible explanation for the results. Where applicable, the sociodemographic and intervening variable data from the sample will be included as a possible reason for the findings of they hypotheses. Study results comparing fathers and mothers (Froemke, 1985) will be included. The relationship of the present study to the conceptual model and the implications of the study for nursing research, education, and practice are discussed. Descriptors of Study Sample The age distribution for the subjects in this study was 21-38, with a mean age of 29.2 (see Table 1). This mean age is similar to Wandersman's study (1980) with first time fathers whose mean age was 27.5 for the parenting group and 28.6 for the contrast group, and Jones (1981) with a mean age of 25.5 years and a range of 19-A2. Similarly, the age range for fathers in Manion's (1977) study on infant caretaking was 20-29 years. Of the fathers who participated in this study, twenty reported being fathers for the first time. Thirty men reported having other children with the range of number of children being 1 to 5. The researchers who limited their study to first-time fathers were Fein (1976), Jones (1981), Manion (1977), and Wandersman (1980). Those Illi- researchers who either did not explicitly state they were studying first-time fathers, or did not limit their data to first-time fathers were Araji (1977), Becker et al. (1975), and Jeffcoate (1979). The reason this researcher chose not to limit the study to first-time fathers was to examine the differences (if any) between responses of the two groups. Forty-seven of the fathers who participated in this study indicated that they were married to the baby's mother. Three fathers indicated they were not married to their baby's mother. All fathers were living in the same household with their baby's mother. All the literature reviewed described their sample of mothers and fathers as either being couples or as being married. Being married to the mother of his baby was a variable that was not necessary for inclusion in this study. Sharing living quarters with the baby's mother was considered relevant because this researchers was studying the fathers perceptions in relation to their being present to be able to take acquired action. Only two researchers reviewed specified the number of years the couples who participated were married. Manion (1977) reported that approximately one half of the couples was married one to three years. Wandersman (1980) reported 3.6 as the average number of years married for the parenting group and A.A years for the contrast group. Becker et al. (1975) included only married couples in their study but did not include number of years married. Becker (1972) states that marital status was a poor predictor of other compliance behavior (knowledge of medications, medication schedules, and follow-up dates). -llZ- The educational level of fathers were reported in a variety of ways. Manion (1977) described her sample as being "well-educated" while Wandersman (1980) listed 3.5 to 3.7 with 3 representing attendance in the college and A being college degree earned. Becker et al. (1975), stated "participants were more likely than nonparticipants to have completed college," while Jones (1981) reported a mean social class typified by a father who was semiprofessional and a college graduate. The fathers in this study varied in their level of education, from "some high school" (82, n I A) to "post graduate or professional education" (122, n I 6). The average education level fell between "completed high school” and "completed college," which would seem to be close to the educational levels reported by other researchers. Collecting information about father's educational level was done by this researcher to further define the sample being studied, because this might influence the level of a father's participation and will be discussed later in this chapter. Comparison of income levels of fathers is difficult. The majority of studies reviewed made generalized statements regarding income levels. Becker et al. (1975) and Markland and Durand (1976) made no reference to income level in analysis of data. Manion (1977) stated only that couples were middle class while Jones (1981) stated only that the sample studied included diverse socioeconomic groups. Wandersman (1980) reported income means of 3.5 for the parenting group and 3.7 for the constrast group, with means drawn from a scale of 1 equaling less -113- than $200 a month income and 6 equaling income of greater than $1,500 a month. All of the participants in this study study (n I 50) reported their annual income. The range was from 0 to $A,999 (122, n I 6) to $A0,000 or above (182, n I 9) annually with a mean of $30,000 to $39,999 per year (see Table 5, Chapter V). Generally, the amount of financial income might influence the perceptions the father has of need to acquire health care. Forty-six of the fathers (922) in this study were white, one (22) was black, two (A2) Mexican-American, and one father answered other (22). Those researchers who included race as a descriptor of their sample reported such statements as ”representing diverse ethnic groups” Jones (1981), "greater proportion of white (participants)" Markland and Durand (1976) and no mention of diversity of sample subjects Manion (i977) and Wandersman (1980). Fathers who participated in this study responded to location of residence in the following manner; urban 26 (522), suburban 10 (202) and rural 1A (282). Markland and Durand (1976) identified population by geographic location. The study subjects were divided into four areas for analysis; major urban, major suburban, out-state secondary cities and rural areas. All fathers who participated in this study returned their completed questionnaire before time of their baby's discharge from the hospital. In reviewing the literature, it is noted that previous studies used varying times to collect data. Data collection occurred anywhere from one day post-partum up to the childs second year of age or more. mu- Becker et al. (1975) studied responses regardless of the age of the participants children. Manion (1977) studied fathers in the hospital and at six weeks post-partum. Questionnaires were filled out by fathers when infants were 2 to 3, 5 to 6, and 9 to 10 months of age (Wandersman, 1980) and in the hospital 2A to 72 hours following birth (Jones, 1981). A study designed to look at all two year olds was undertaken by Markland and Durand (1976). Data for this study were collected within the post-partum period while the baby was still in the hospital. This is a time when a father's elation might be at an all time high and before adjustment begins. Because of this period of post-birth elation, father's responses might not be representive of their true perceptions and, therefore, limit the ability to generalize results. In summary, the descriptive findings from this study sample have been presented. Similarities and differences have been discussed as they related to this study and compared and contrasted to the studies of other researchers. In the next section the hypotheses will be stated and discussed. A statement indicating whether the hypotheses were accepted or not accepted is provided along with a possible explanation for the findings. Where applicable, the descriptive findings from this study will be applied. Because the questions concerning the intent to acquire immunization produced no variation in response, it was not possible to utilize Pearson product moment correlation. Therefore, responses to the Health -115- Belief Model dimensions of perceived susceptibility, perceived severity, perceived benefits, and perceived barriers could not be shown to have a relationship to intent to acquire immunization. Hypothesis I: There is a positive relationship between a fathers perception of susceptibility to common childhood disease and the intent to acquire immunization for a child. Eleven items were utilized in the analysis of perceived susceptibility. Each item had four response categories that could render possible scores from 11 to AA for susceptibility. The actual mean susceptibility item score was 33.7 with a response range of 2A to AA. Although the hypothesis could neither be accepted or rejected the data showed a tendency for the subjects to score towards the high end of the susceptibility scale indicating that fathers had a high level of perceived susceptibility toward common childhood disease. Becker et al. (1975) who studied perceived likelihood of carrying the Tay-Sachs gene and voluntary participation in a mass screening program found that 762 of participants with high perceived susceptibility participated in the mass screening program. Other researchers whose studies were reviewed did not look at fathers perceptions. Although this dimension could not be correlated to intent to acquire immunization there are some interesting patterns to responses to individual questions which have implications for this study. When fathers were asked to respond to the statements it is possible my child -116- could get polio (; I 2.5A), or pertussis (i I 2.86), answers clustered around the response category "disagree." In contrast, when asked questions concerning the possibility of getting a bad cold (i I 3.3A), getting a bad cut on the arm (; I 3.32), drinking something poison (Y’I 3.02), or developing strep throat (i'I 3.2A) answers clustered around the response category "agree.” Although intent to acquire immunization could not be correlated to perceived susceptibility, a possible explanation for this study's findings might be that the actual acquisition of immunization might not be done in a timely manner due to the perceived susceptibility of their child contracting a common childhood disease being too low. In other words, the fear of their child contracting the disease was not high enough. Responses indicate that fathers do worry about such things as strep throat, drinking something poisonous, getting a bad cut or developing a bad cold. These are all diseases that are not protected by immunization, therefore fathers are more likely to seek health care for them. Hean score for susceptibility alone is not to assess what the immunization behavior of fathers would be. While perception of susceptibility might be lower, the perception of severity might be high enough to counteract this, thereby influencing his decision to act. Hypothesis II: There is a positive relationship between a fathers perception of severity of common childhood diseases and the intent to acquire immunization for a child. -117- Eleven items were utilized in the analysis of perceived severity. Each item had four response categories that could render possible scores from 11 to AA. The actual mean severity item score was 36.2 with a response range of 27 to AA. This data showed a tendency for the subjects to score towards the high end of the severity scale, indicating that fathers had a moderately high level of perceived severity toward common childhood disease (see Table 7, Chapter V). Becker et al. (1975) found a striking association in perceived severity but in a direction opposite to that observed for susceptibility. Those whose perceptions of severity were toward the low end of the scale participated significantly more frequently in mass screening than did those who believed that knowing their carrier status would have a greater impact. Becker explains this as "it would appear that, while a low or moderate estimation of severity is necessary to motivate the individual, the perception that being a carrier would be highly disruptive of future family planning seems to have an inhibiting effect on participation” (Becker, et al, 1975, p. 7). Although no relationship could be shown between fathers perceived susceptibility and intent to acquire immunizations, content analysis for the dimension of perceived susceptibility identifies a pattern of responses having implications for health care providers. There was a higher perceived severity for diseases that could not be prevented by immunization. Diseases such as asthma (i I 3.08), infection developing from a cut on the arm (i I 3.16), and accidently drinking something poisonous (i I 3.50) produced means in the ”agree" -118- to "strongly agree” response categories. Fathers perception of severity was lower in response to categories such as; chicken pox (i I 2.86), immunizing my child will make them sick (i I 2.13), mumps (i I 2.90) and whooping cough slightly higher with a mean of 3.16. Therefore, fathers have a higher perception of severity for diseases not prevented by immunization. This may be from lack of knowledge about the diseases due to low incidence in the general population. The implication for this study is the perceived level of severity for communicable diseases being low to the point that fathers might seek immunization for their child without outside intervention, suggesting that intervention strategies need to be developed to be utilized to target population identified at risk for non-compliance to acquiring immunization. Becker et al. (1975) found that a low or moderate estimation of severity is necessary to motivate an individual to participate in Tay-Sachs screening. It is difficult to assess the immunization behavior of fathers based upon mean score for severity alone. Hypothesis III: There is a positive relationship between fathers perception of benefits of a vaccine and the intent to acquire immunization. Eleven items were utilized in the analysis of perceived benefits. Each item had four response categories that could render possible scores from 11 to AA. The actual mean benefit item score was 27.0 with a response range of 11 to 35. Although no relationship could be shown between fathers perceived severity and intent to acquire immunization -119- the data showed a tendency for the subjects to score towards the middle of the benefit scale, indicating that fathers had a moderately low level of perceived benefits. Responses to statements such as a health care provider could cure/prevent polio (i I 2.95), chickenpox C; I 2.A1), mumps (i I 2.A9), measles (i I 2.59) and whooping cough (R'I 2.67) indicate that fathers did not see benefits in seeking out a health care provider for communicable diseases and may reflect one's belief in the value and benefits of immunization. Another possibility is that the wording of the statements with cure/prevent was confusing to fathers. These two words actually have different meaning. No specific literature could be found that talked about fathers seeking immunizations for their children. Because fathers and mothers scored similarly in responses to benefit statements extrapolation of findings from a study on mothers beliefs regarding the preventive health care (Becker, et al., 1977) found that mothers beliefs regarding the value of preventive health measures and positive feelings about the sources of health care have found to be associated with preventive action taken on behalf of their children. Although fathers indicated little value in seeking out a health care provider (nurse/doctor) for communicable disease, they did indicate overwhelmingly that they did "intend” to have their newborn child immunized. This response could be as a direct result of confusion from the wording "cure/prevent” in the benefit questions. Fathers may see value in acquiring immunization for their newborn child but does not see the disease as curable. Il20- Haefner (197A) developed a study that measured mothers beliefs about the value of early dental visits as a predictor of regular dental visits for children. He found that mothers who did not see the value of early dental visits also did not adhere to routine visits for immunizations and obtained fewer immunizations for this child. This indicates a belief in the benefits of immunization to be correlated to higher immunization levels. Hypothesis IV: There is a positive relationship between fathers perception of barriers to immunization and the intent to acquire immunization. Although this subscale was shown to lack variability on response to questions to elicit barriers and no definitive statements can be made, there are implications for the present research, a descriptive analysis of the barriers subscale is provided. Seven items were originally utilized in the analysis of perceived barriers. This rendered a coefficient alpha of .30. It was found that fathers' response was clustering on opposite ends of the scale. In order to improve the reliability of this subscale, one item was deleted by the investigators which read "There isn't much anyone can do about common childhood illnesses." It was found that this item elicited the lowest item reliability and it was felt by the investigators to be an ambiguous question. Additionally, the scale was reduced from a four response to a two response format. Each item could be scored from 1 to A. The response categories could then render possible scores from 6 to 2A. The adjusted barriers total mean score was 8.5 with a response -121- range of 7 to 12. Subsequently, the alpha coefficient for fathers perceived barriers increases from .30 to .AS. Although no relationship could be shown between fathers perceptions of barriers to health care and acquiring immunization for their child, the data showed a tendency for subjects to score toward the low end of the scale indication that fathers had a moderately low level of perceived barriers. Generally fathers perceived all barriers to acquiring immunization for their child low. Rosenstock (197A) states that benefits must outweigh barriers in order for an action to occur. The concern from this study is whether fathers perceptions of benefits to acquiring immunization is great enough to overcome the perceived barriers. The barrier subscale has, typically, elicited a low reliability (Janz, 198A). Results from this study for fathers perceived barriers supports this finding for low reliability. Perhaps fathers are not able to predict what actual barriers to acquiring health care and/or immunizations will be. The present researcher attempted to elicit fathers responses to seven different barriers, perhaps the barriers identified were not those experienced by the fathers who participated in the present research, or barriers had not yet been experienced. Cues to Action A cue is a critical incident which propels or motivates an individual to take action. In an attempt to identify sources of influence that fathers utilize to make decisions concerning the health care of their child/children several responses were given. Most often -122- the fathers cited the physician (n - 39), their spouse (n I 36), and themselves (n I 32) as a source. Family and friends and the nurse were seen less often and no fathers indicated that they had read information in books or magazines to influence their decisions concerning health care. The sources which 993; influenced their decision concerning the health care of their child was the physician. This finding is consistent with those of Becker (1972) and Markland and Durand (1976) who did studies on the health care seeking behavior of mothers obtaining immunizations for their children where both researchers were able to show that the private physician plays a major role in parents compliance. Fathers appear to rely on themselves, the physician, and their spouse in making health-care related decisions. No fathers saw the nurse as a source which 222$ influenced their decision to acquire health care for their child. This poses an ominous challenge for nurses in the advanced practice role. Not only do we have to provide comprehensive health care based on knowledge, we have to be continually aware of the old stereotypic image of the nurse, that of being the ”hand maiden” to the physician. We need to develop ways to dispel that image and this can best be done by providing teaching that includes the father. Very few fathers were able to state the correct age to begin immunizations. When the fathers response for correct age was added to the mothers response, a level of significance was found and this was significantly correlated with having heard or read information RL IL -123- regarding immunization. Possible reasons for this are the mothers were correct often enough to "pull up" the fathers scores or fathers, although they indicated what they read or heard did not effect the decisions they made concerning immunization had, in fact, retained knowledge from what they had read. General Health Motivation General health motivation states that frank motives toward good health do exist. Four items were originally utilized to measure general health motivation. Each item had four responses that could render possible scores from A to 16. Actual mean general motivation item score was 8.5 with a range in response from 7 to 16 and a coefficient alpha of .A6. it was found that fathers responses were clustering on opposite ends of the scale-either "agree" or "disagree." In order to improve the reliability of this subscale, one item was deleted by the investigator which read "I plan to buy special foods to improve or protect my family's health." It was found that this time elicited the lowest item reliability and it was felt by the investigator to be an ambiguous question. Additionally, the scale was reduced from a four-response to a two-response format. Subsequently, each item had a response range possible from 3 to 12. Actual mean general health motivation item score was 8 with a range in response from 5 to 12 and a coefficient alpha of .52. 424- In this study fathers had a low response to general health motivation questions that applied to themselves. Concern about their own health (i I 2.98), concerned about getting sick (i’- 2.88) fell into the category of ”disagree." One item resulted in a slightly higher response. Planning to give their child vitamins had a mean of 3.02. Because the alpha coefficient remains low, no definite statements about the scale for General Health Motivation can be made. If preventive health orientation is a predictor of health seeking behavior then one might conclude that fathers are not concerned enough about their own health care needs and might not be motivated enough to seek preventive health care for their child. Correct vs. Incorrect Age Fathers were then asked to indicate at what age they would begin immunization for their newborn child. The range of responses was age one to twelve months with a mean of four months. Reasons given for why they had chosen the age they did varied greatly. Fourteen fathers (282) indicated they would do what the doctor said. Eight fathers (162) indicated they would do what was best for baby. Two fathers (A2) said as soon as possible and four other fathers (82) indicated they didn't know. One father (22) stated it would be based on weight and one father (22) said he would base starting immunizations on information he had read. Twenty fathers (A02) gave no response. When fathers were asked if they had read or heard any information concerning immunizations 2A (A82) responded "yes." Only five fathers who had responded that they had read or heard information concerning -125- immunization were able to give the correct age for beginning immunizations. Twenty fathers (A02) gave no response when asked to indicate at what age they would begin immunization for their newborn child. This large number of fathers not giving response has implications for the nurse in advanced practice. A part of nursing practice is to provide education to the client. The father, as a parent expecting a child, should have education provided that includes the need for immunization as well as age to start and correct intervals of administration. No statistical significance was found when this researchers correlated responses to intent to acquire to father's age, level of education or number of older children. Implications for this research are great. Overwhelmingly, fathers indicated that they did intent to have their newborn child immunized. What was apparent from answers to the second question was that very few fathers knew ypgp they should begin immunizations. This is indicated by the high number of incorrect ages as well as ”incorrect" reasons for when to start immunizations, particularly those such as based on weight or as soon as possible are a direct indication of lack of knowledge. Additionally, fathers want consequences of immunizations explained, immunizations made free, made a state law and to be educated while in the hospital as well as making it easier to get to a clinic to obtain immunizations. While the suggestions are valid, it does indicate a sense of "outside decision making." The health care provider will have to meet these needs when she/he has contact with the father so as to best be able to help him take responsibility for acquiring health care. ~126- Hypothesis V: There is a positive relationship between fathers' perceptions of susceptibility of common childhood disease and mothers' perceptions of susceptibility to common childhood disease. Hean response for fathers to susceptibility was 33.7. Mean response for mothers to susceptibility was 33.7. Because of the lack of variability in the response to perceived susceptibility, no definitive statement can be made. Therefore, the hypothesis can be neither accepted nor rejected. Hypothesis VI: There is a positive relationship between fathers' perceptions of severity of common childhood disease and mothers' perceptions of severity to common childhood disease. Mean response for fathers to severity was 36.2. Mean response for mothers to severity was 36.6. Because of the lack of variability in the response to perceived severity, no definitive statement can be made. Therefore, the hypothesis can be neither accepted nor rejected. Hypothesis VII: There is a positive relationship between fathers' perceptions of benefits of a vaccine and mothers' perceptions of benefit of a vaccine and their intent to acquire immunization for their child. Mean response for fathers to benefits was 27.1. Mean response for mothers to benefits was 27.1. Because of the lack of variability in the response to perceived benefits, no definitive statement can be made. Therefore, the hypothesis can be neither accepted nor rejected. -127- Interpretation and Limitations of the Findings There were limitations to the findings in terms of several of the characteristics of the sample. The majority of fathers were well educated, had higher incomes and were white. Collection of data was done immediately following the birth of the child while fathers may be in a "honeymoon” stage, thereby altering their perceptions and ultimately affecting the results. Also, people will tend to respond in a socially desirable manner. This is probably more true of new parents who want to be ”good parents" and do all the right things for their new baby. In addition, all study subjects were married to or living with the mother of their baby. Different responses might result from a single parent population or parents from other cultures. Finally, the sample of subjects was small (n I 50) and data collected over a short (five week) period of time. Therefore, the sample may have differed in some way from the general population. A sample drawn over a longer period of time and from a broader community base might have held different perceptions about Health Belief Model dimensions and the intent to acquire immunization for their child. The major limitation to the study was the lack of variability of response to the question asking “intent to acquire." With no variability in response it was not possible to make a correlation to susceptibility, severity, benefits, or barriers and impossible to test the hypotheses. -128- Summar In summary, it was found that fathers and mothers do not differ significantly along any of the Health Belief Models dimensions of perceived susceptibility, severity or barriers. In fact, fathers and mothers tended to respond with almost identical mean scores with the exception of general health motivation. Also, neither fathers nor mothers saw the nurse as influencing their health care decisions. A trend was found in which mothers appeared to have a higher perception of general health motivation than did fathers. What this indicates is that primary health care providers should be able to talk to fathers and mothers together or independently and be able to achieve the same level of understanding regarding immunizations. Both fathers and mothers were unable to give correct ages or reasons for immunizing their child, nor was the presence of other children in the family a factor influencing the correct answer, however, reading or hearing information significantly influenced ones ability to cite the correct age. The differences between fathers and mothers are few and we can assume as health care providers that our intervention strategies for fathers will be as effective as our interventions for mothers. However, many other factors, not included as a part of this study influence not only the opportunity to initiate these strategies but also the success in carrying them out. -129' Implications for Nursing Education Implications of the study findings for nursing education are pertinent for both graduate and undergraduate programs and staff development. The fact that substantial numbers of children are inadequately immunized against childhood disease (DHHS, 1980) has direct implications for the nursing profession. Awareness of a father as a health care consumer, as well as what will facilitate or prevent having his children immunized, and an understanding of fathers' perceptions of common childhood diseases and immunization are important in seeking solutions to the problem. Haggerty (1983) stated that nursing is defined by what is taught in our nursing schools, our practice is a product of what is taught. "The legal basis for the practice of nursing at all levels lies within the profession itself" (p. 12), therefore, the nursing profession should take the initiative to integrate the effects of perceptions of health status and the acquiring of health care as well as an awareness of the effects of medical, sociopsychological and economic demographics and how they influence the acquiring of health care into nursing curriculum. The complexity of evaluating the level of a clients likelihood to acquire health care is considerable. Skill in advanced assessment techniques as well as use of the dimension of the Health Belief Model to aid in evaluation needs to be developed. This is only done through education, research and practice. Nurses in programs of less than a masters level have been educated to use nursing process and -130- they need to be taught also, how to apply this knowledge outside the acute care setting. The Clinical Nurse Specialist, in advanced practice has been prepared in interviewing, assessment and problem solving skills and is qualified to apply these skills to managing the health care needs of the child in the primary care setting. As the nurse-client interaction process is more fully explored the complexity revealed by factors that support the assessment of perceptions for the purpose of goal attainment (King, 1981) and effective interventions can be developed for the 1990 goal of the Public Health Services, Department of Health 8 Human Services, that 902 of all children have their basic immunization series by age two. The specific needs for nursing education and continued staff development derived from the findings of this research are to have a factual knowledge base about common childhood diseases and the needs and requirements for immunization and be able to articulate this knowledge to clients. Implications for Nursing Research Nurses have a unique opportunity to search for and test solutions to inadequate immunization levels for children because of their role in both client education and preventive health care. A number of implications for further research may be derived from this study. Replication of the research would not be useful in the present format. Lack of statistical significance between perceptions of susceptibility, severity, benefits, barriers and intent to acquire immunization due to lack of variability in response to intent to acquire greatly limit the practicality of replication. -13]- "Numerous research findings on the Health Belief Hodel are now available so it is unlikely that additional work of this type would yield new information" (Janz 8 Becker, 198A, pg. 57). Use of the Health Belief Model dimensions in this study revealed findings consistent with the literature, on a theoretical basis. This research would best benefit from expansion to include follow-up contact of subjects over a six to 18 month time period to ascertain the continued acquisition of immunizations over time. This would allow the researcher to look at barriers retrospectively, making more accurate identification of barriers possible. "While the Health Belief Model specifies relevant attitudes and belief dimensions it does not dictate any particular strategy for altering those elements" (Janz 8 Becker, 198A). Expansion of this study to include an experimental and control group, with the experimental group being treated with an intervention such as being sent a reminder card or given a reminder phone call would allow the researcher to compare results for statistical significance. There is a lack of experimental design to evaluate the efficacy of intervention in modifying perceptions of susceptibility, severity, benefits and barriers to achieve desired health behavior. A large number of items to elicit actual barriers and the development of questions through factor analysis to assure measurement of unified concepts is necessary. A concern made evident by this study is that barriers are very personal, especially for higher income and educational groups, therefore, there would again be the need to look -132- at barriers retrospectively. There also exists a need to refine and standardize tools used to measure Health Belief Model dimensions. This could be done by developing a large number of questions for each dimension with repeated testing and factoring between two separate populations. this repeated factoring would assure measurement of unified concepts. Questions should also be developed that tap knowledge directly as well as indirectly. This would allow the researchers to compare a fathers actual knowledge with his intent to acquire health care for his child and to identify those fathers considered to be "high risk." Fathers identified as high risk and with known low compliance levels could be targeted with specific intervention strategies in an attempt to modify health seeking behavior. A final area to consider for further research would be to look at different populations. Fathers might include those from other ethnic populations or divorced or single fathers. Also questions could be developed that look at internal and external locus of control, and other factors that enter into the decision making process, l.e., religious beliefs. Implications for Nursing Practice The implications for nursing practice which can be drawn from this study are based upon the conceptual framework, review of literature, and study findings related to the individual perception subscales of susceptibility, severity, benefits, and barriers. -133- Implications can also be drawn from the relationships between the perceptual subscales, the modifying factors and the motivational "cues to action." In the theory for nursing developed by Imogene King (1981) goal attainment was derived from the conceptual framework of interpersonal systems. The nurse and the client (father) is one type of interpersonal system. Some of the major concepts in the theory of goal attainment are interaction, perception, communication and transaction. "Interaction is defined as a process of perception and communication between person and environment and between person and person" (p. 1A5). When fathers were asked to indicate who and/or what influences the decision they make concerning the health care of their child, 12 fathers (2A2) indicated the nurse as a part of their response. When asked to indicate the ppg which 9235 influences their decision concerning the health care of their child the nurse was not indicated. There are several possible reasons for these results; the fathers have had little to no contact with nurses, or the fathers do not recognize the knowledge the nurse has on this subject, or the father values someone elses recommendation more. For whatever reasons, this finding has major implications for nursing practice. Inherent in the model of goal attainment (King, 1981) is the need for communication between the nurse and the client, this might not be possible if the client (father) does not look at the nurse as a source of influence. -134- In Kings (1981) goal attainment model, compliance with the therapeutic regimen is an indicator that transaction has taken place, preceded by accurate assessment and mutual planning. Assessment includes taking into account the clients level of knowledge and perceptions of disease susceptibility and severity. The nursing practice implications of this research are the need for ongoing assessment and evaluation of the client's perceptions of barriers to acquiring health care, the health and/or doubt of immunization efficacy, and the clients ability to carry through with the desired regimen. In person to person interactions, each individual (the father and the nurse) bring different knowledge, experience, needs and perceptions that influences the interaction. It is here at the interaction phase that the nurse is best able to influence the behavior of the father and it is here that intervention can begin. Compliance with acquiring immunization for their child Is an indicator that mutual transaction has taken place, preceded by assessment and mutual planning. Assessment includes taking into account the clients perceptions of susceptibility and severity of disease. "It would not be an exaggeration to say that most people perceived the communicable disease of childhood as either a thing of the past or else something children must go through as sort of a necessary rite de passage" (lmperato, 1977, p. 1791). -135- Nurses have contact with fathers (parents) during the pre- and post-natal period and throughout the child's early years. They can identify parents and children at risk earlier if they have knowledge of characteristics of families who tend not to seek immunizations for thier children. If a father (parent) has no knowledge of a disease or its consequences, it is doubtful that he will perceive his child as susceptible to that disease. Introduction to the immunization process can be started at the time of the first contact with the client and should include a basic understanding of common childhood diseases, the consequences of these diseases and the part immunization plays in avoiding or decreasing the harmful effects of the disease process. The contact can be made during prenatal checks in the form of pamphlets or short video tapes and should include the mother as well as the father as much as possible. Other places of impact for introduction should be in the hospital setting during the post-partum period or before delivery while conducting expectant parent classes. The ability to identify through parents, sociodemographic factors, the infants at greatest risk for not receiving immunizations, would be of great value to the nursing profession. A short questionnaire given to each father/mother at time of first contact could aid in identification and be utilized as an early warning to help identify infants for promotional mailings tailored to -136- the parent's needs and characteristics. Identification of ”high risk infants" could also be used by public health nurses for home visits (Markland 8 Durand, 1976). As nurses in advanced practice, we need to be aware of the demographic profile of those persons who are most likely to obtain health care in general and those who are not and these people should be targeted for increased intervention effort. In practice, nurses should encourage the father to attend prenatal and post-partum exams. During the appointments, the nurse should include the father by involving him in teaching, encourage him to ask questions, and deal with any concerns he may have either pre-natally or during the post-partum period. The nurse should be visable and available, she should encourage the father at all times to take an active part in preparing for parenthood. After the baby is born, the father is often lost to the health care providers. Generally, only the mother returns for the post-partum and well-child checks. This system often leaves the father with unanswered questions. In a primary care setting it would be more likely that the entire family would seek health care in the same setting and this practice should be encouraged. During the post-partum period the nurse should recognize that the father may need additional support, role reinforcement or definition, and guidance. During interaction, the nurse should assess the level of the adjustment being achieved by the father and answer questions or deal with concerns that have arisen about the baby, themselves, or each other. -137- Anticipatory guidance and problem-solving are areas the nurse should discuss when meeting with the parents. How the new baby will effect the fathers life needs to be explored. Areas to anticipate are change in personal time, division of labor on housework and change in role to include father to that of husband, provider, etc., and the effect these changes would have on the father. Nurses should be familiar with community resources that would aid the expectant father by offering information, assistance or programs for fathers (parents) to attend. It is part of the role of the nurse .‘ to let fathers (parents) know what resources are available within the community. Nurses who work with expectant or new fathers should share their resources with other nurses who work in similar areas. This will aid in updating and increasing his knowledge base, and ultimately increasing benefit to fathers. The over all goal of nurses who work with fathers (or parents) should be to assist them in promoting their own self care. By doing this the nurses reinforce the father's adoption of his new role. By assisting the father to prepare for parenthood, the nurse is helping to decrease the concerns the father may have following the birth of his baby. Another necessary part of advanced practice is to be aware of the dimensions of the Health Belief Model to predict preventive health behavior and utilize this in our assessment of the client. This will aid in mutual goal setting and the ultimate outcome of optimal health for the client. -138- Summary In Chapter VI, a summary and interpretation of study findings was presented. It was shown that there are minimal differences between fathers and mothers perceptions of the Health Belief Model dimensions and their intent to acquire immunizations for their newborn child. Findings related to the conceptual framework of this study and to nursing theory are important to the nurse in advanced practice. No fathers or mothers saw the nurse as a resource person nor as influencing the decision to acquire health care for their newborn child. As a Clinical Nurse Specialist in advanced practice, we need to become more visible in such a way that we may be seen by health care consumers as a person of both knowledge and expertise. Also included in this chapter are recommendations for nursing research, education and advanced practice. -139- References Aho, W.R. (1977, January-February). Relationship of wive's preventive health orientation to their beliefs about heart disease in husbands. Public Health Reports, 33(1), 65-71. Academy pertussis task force meets. (198A, September). American Academy of Pediatrics Newsletter, 33(9), 1-2. American Academy of Pediatrics, Committee on Standards of Care (197A). Recommendation for preventive health care of children and ygggfl. Evanston, IL: American Academy of Pediatrics. Amler, R.W., Black, A.B., Drenstein, W.A., Bart, K.J., Turner, P.M., 8 Hinman, A.R. (I982). Imported measles in the United States. Journal of American Medical Association, 2A8(17), 2129-2133. Anderson, G. (1962). 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(1980). The adjustment of fathers to their first baby; The roles of parenting groups and marital realtionship. Birth and the Family Journal, 3, 155-162. Williams, W.O., 8 Dajda, R. (1980). Validation of sources of pertussis immunization data. Journal of Epidemiology and Communlgy Health, 301), 309-311. APPENDIX A Human Subjects Review Approval Hospital Approval of Study Protocol XICHIGAN STATE UNIVERSITY mam MM'WOmIJl? - -9- l Mia-116m STATE ' UNIVERSITY JAN 04 1985 mwmm m Jamar, 8, 1,985 ‘10: leery eredeck. ms this letters Given, Ph.D., l.l., 1.1.1... Director for the Graduate Program In: Ieidi rzoedte's sod Lyn O'Connor's Thesis Proposal mese students have presented their thesie peoposel to their eo-ittee adhere. use co-ittee hes positively reviewed their proposed research project for their 11.8.11. progre- within the College at lensing. IP11 mb-MWW“ I. Abstract This study has been designed to determine within a specific population what are those perceptions and beliefs held by parents concerning childhood diseases and vaccines which influence immunization of their children. This study is being done in response to a growing lack of immunizations among preschool children in the United States. The overall objectives of this study are to determine those perceptions/beliefs held by both mothers and fathers concerning childhood illnesses and vaccines which influence their decision to immunize their children. 1. Determine those perceptions/beliefs which most influence a parents decision to immunize. 2. Determine perceptions/beliefs which least influence a parents decision to immunize. 3. Determine how mother's and father's perceptions/beliefs differ and/or are similar. A. Determine the role health care providers can play in influencing parents behavior. It is believed that by better understanding those perceptions that influence the parents decision to acquire immunization for their children, health care professionals may function more effectively to encourage immunization, thereby, enhancing child health status. xi II. Study Sample Subjects will be volunteers chosen from those women having just delivered an infant at St. Lawrence Hospital's post-partum unit. Additionally, the husband or boyfriend/father of that child will be asked to participate. Selection will be further restricted to those mothers and fathers who are at least 18 years of age and who are able to read and write English and who have delivered a normal child. Subjects will be recruited at the post-partum unit of St. Lawrence Hospital during the post-partum period in which mothers are still in the hospital. The investigators, with assistance from nursing staff, will offer the questionnaire to all mothers and fathers meeting the criteria for the study. Parents meeting these qualifications will be informed that a study is being conducted by graduates students from the Michigan State University College of Nursing, to better understand parents attitudes toward childhood illness and immunizations and that they are eligible to take part in the study. Those expressing interest will be given a questionnaire and explanatory letter in a stamped, addressed envelope. Parents who decide not to take part in the study will be thanked for their time and interest and requested to return the blank questionnaire. xii III. Risk-Benefit Analysis A. Potential Risks The study involves no physical, psychological or social risks to the parents who take part. Any parent is free to refuse to fill out the study questionnaire, or after beginning the questionnaire, is free to terminate completion at any point. Parents will be assured that refusal to participate will not alter the quantity or quality of the care the mother and child are receiving at St. Lawrence Hospital. Parents will have the opportunity to discuss their participation in the study and questions will be encouraged. Becoming a study participant will involve no financial expense to women who volunteer. B. Procedures for Protection of Participants The anonymity of study participants and confidentiality of their responses will be protected by the following procedures: 1. Questionnaires will be given to study participants and returned by them in sealed, unmarked envelopes. Neither the hospital staff nor the investigators will view any questionnaire which could be directly associated with an individual participant. 2. Identifying numbers only will be used to match mothers and fathers responses (e.g., 1A, 18). 3. Information from completed questionnaires will be released in aggregate form only. A. Institutional/organizational names will be omitted in public presentations and/or reports. xiii IV. Potential Benefits of Study Potential benefits of the individual subject participating in this study include a heightened awareness of their own perceptions/beliefs as they influence seeking specific health care for their child/ children. Additionally, both women and men may benefit from an increased awareness of the shared responsibility in the health care of a child. Further, participants may develop an increased awareness of the availability of information and guidance from health care providers. Health care providers will benefit from an increased understanding of those perceptions/beliefs which influence immunization-seeking behavior in both mothers and fathers. Counseling and education for parents may be more efficient and effective when areas of concerns and/or misconceptions are accurately identified. V. Consent Procedure Potential participants who meet eligibility requirements of the study will be identified by staff nurses at St. Lawrence Hospital to the investigators. Eligible parents will be approached by the investigators, informed that a study concerning child health and immunizations is being conducted and inviting their participation if they so desire. To those expressing an interest, the investigators will explain the study and present the Opportunity for discussion and questions. Confidentiality and anonymity will be assured and each individual will be informed that they may withdraw at any time without penalty. XV VI. Study Instrument A draft of the questionnaire to be used for the measurement of those perceptions surrounding childhood illnesses and immunizations is attached. The explanation of the study will advise the individual that their answers will be anonymous and confidential and that they are free to withdraw from the study at any time without penalty. xvi Dr. Scott Swisher Medical Chairman Research Committee St. Lawrence Hospital Lansing, MI A8917 Dear Dr. Swisher: We are graduate students in the College of Nursing at Michigan State University and are currently involved in completing our Masters thesis. In response to the low immunization levels among preschool children in the U.S., we are interested in identifying and measuring parental (mothers and fathers) perceptions of childhood illnesses and vaccines. It is our desire to measure these attitudes in new parents and, would, therefore, like to use the post-partum unit of St. Lawrence Hospital as the study site. Enclosed, you will find a copy of the proposal questionnaire along with the abstract required by the Human Subjects committee at Michigan State University. This is being sent to you for consideration and approval at the October meeting of the St. Lawrence Hospital Research Committee. Very truly yours, Heidi Froemke Lyn O'Connor xviii ' AWN/Own m R! mm. WGATIGI 35423-5 'lu'entlfying and Measuring Flarentai Perception of Qinical “and“ 01101006 illness and VICC‘IMS. Heidi Froemke. “1.. Lyn U umnor, mil. ties mm a “NEE 2! 13: t. m THE mm: mama's: -/A Medical Staff' smor met oversee the study T and last have Hor a novel of dent‘s Ician. (0r. Gerard nuitzer has volunteered to he the eedicai staff sponsor if you so desire. mmmmema—sficmummm mnmnmuumw meantinndmmsoithissmeyshnlhefin-Ilyuvuwdoy‘aem morheeore . its Ifywcmcludeyotriuvesitpdmpdorto daisdste, pleeseinfisnthe Cc-ittee. Origiml - file any - investigator copy - pinneq T-lOOZ LI.- APPENDIX 8 Selection Criteria Checklist Selection Criteria Checklist Both parents (the biological father and mother) agreed to complete and return the questionnaire. Both parents must share the same household. Both parents must be age 18 or over. Both parents must be able to read and write English. The newborn infant would be "normal" i.e., no genetic defects or congenital malformations. XX APPENDIX C Letter of Explanation Dear Parent: This letter is to introduce you to a study which is being conducted by Heidi Froemke, R.N., and Lyn O'Connor, R.N., graduate students in the Michigan State University College of Nursing. There are many things which help parents decide to acquire health care for their newborn child and/or children. This research study is being done to help health care providers better understand why parents seek this health care or not. It is the hope of the researchers that the information collected many help health care providers to give the best information to parents to help them acquire health care for their child/children. This study will take about twenty mlnutes of your time. Please complete the questionnaire about your health practices and your baby's health. There are also questions about yourself, your culture, and income on the questionnaire. We do ask that mothers and fathers fill out the questionnaire independently. This study will in no way affect the are you are now receiving. There is no physical risk or expense to you. You may feel free to ask questions. Your identify will be unknown and no information that could identify you, in any way, will be used in research data. Your answers to the questionnaire will not be revealed to any other person. The results of this study will be made available to you when the study is ended, at your request. Completion and return of this questionnaire implies the giving of your consent to use the data for research purposes. Thank you for your time and consideration. Please return the questionnaire in the enclosed stamped and addressed envelope. If you have any questions or concerns, feel free to call us at 517/355-2975. Sincerely, Heidi Froemke, R.N. Lyn O'Connor, R.N. xxi APPENDIX D Study Questionnaire The following questions describe general things about you. Although we would appreciate your answering every question, if you should find one that is offensive to you, please feel free to leave it blank and go on to the next question. Please do not discuss your answers with each other until you have completed the questionnaire. 1. Parent filling out questionnaire (check one): (1) Mother ___ (2) Father 2. Age: 3. Ethnic background (please check only one category): (1) White (2) Black (3) Mexican-American (A) Oriental (5) Americzirlndian _ ('6'). Other _ (specify, _ A. Marital Status (check one): (1) Married ___1 (2) Separated ___ (3) Divorced ___ (A) Single ___ 5. In what town do you live? 6. Formal education completed by each parent (check one): Mother: (I) 8th grade or less (A) Some college (2) Some high school (5) Completed college (3) Completed high school (6) Post graduate work Father: (I) 8th grade or less (A) Some college (2) Some high school (5) Completed college (3) completed high school (A) Post graduate work 7. Income: total combined family income for the last 12 months (check one). (1) 0 - I1,999 _ (5) 20.000 - 24,999 __ (2) 5,000 - 9,999 _____ (6) 25,000 - 29,999 ._____ (3) 10,000 - IA,999 ______ (7) 30,000 - 39,999 ,_____ (A) 15,000 - 19,999 (8) A0,000 - above (9) Don't know 8. Child's birthdate: 9. Sex: Male Female Twins , sex 10. How many other children do you have? If none,,gp directly_lo question #16. xxii ll. ‘2. 13. 1A. 15. l6. 17. 18. 19. What are the other childrens ages? Have these older children received any humunizations (baby shots)? Yes No Don't Know Would you check the imnunizations that you remenber they have had? (I) DPT (2) IN! (Measles, Mums, Rubella) __ (3) Oral Polio ____ (A) Other (specify, ) Where did your child get these shots (check one)? (1) Public Health Department: (2) Private Physician: (3) Other (specify): If your other child/children has not received all his or her shots, what is the reason they are lacking (circTE)? (1) Long-term illness (2) Not enough time (3) Not enough money (A) Not old enough (5) Other, explain Who and/or what influences the decision you make concerning the health care of your child (check all that apply)? (1) Nurse ___ (2) Doctor ___ (3) Family 8 Friends ____ (A) Spouse ___ (5) Magazines, Books, Newspaper ___ (7) Myself ___ (8) Other ___ Check the pp; which most influences your decision concerning the health care of your child (check one). (1) Nurse ___ (2) Doctor ___ (3) Family 8 Friends ___ (A) Spouse ___ (5) Hagazines, Books, Newspaper ___ (7) Myself ___ (8) Other ___ Have you read recently in magazines, books or newspapers, or heard over radio or T.V., any information about imnunizations (check one)? (1) Yes (2) No If yes, please answer question 19, below. Was the information "for" or "against" inmunization? (I) For (2) Against xxiii Please answer every question to the best of your ability. There is no right or wrong answer. Please circle one response for each question. 20. It is possible my child could get a bad cold. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 21. It is possible my child could get mums. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 22. My child could be paralyzed if he/she developed polio. (l) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 23. I am concerned about my own health. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 2A. I an concerned about the chance of getting sick. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 25. I plan to give my child/children vitamins regularly. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 26. If my child developed asthma I would worry. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 27. My child could get an infection if he/she had a bad cut on the arm. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 28. It is possible my child could develop anemia or low blood. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 29. It is possible my child could accidently drink sanething poisonous. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 30. It is possible my child could get polio. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree xxiv 31. 32. 33. 3A. 35. 36. 37. 38. 39. A0. A1. A2. It is possible my child could develop whooping cough (pertussis). (l) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree It is possible my child could get asthma (wheezy breathing). (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree My child could get pneumonia if he/she developed a bad cold. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I would worry if my child developed mumps. (I) Strongly Disagree (2) Disagree (3) Agree (‘1) Strongly Agree A health care provider (doctor or nurse) could cure/prevent chicken pox. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I would worry if my child developed measles (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I would worry if my child developed anenfia or low blood. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I would worry if my child accidently drank something poisonous. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent polio. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent asthma (wheezy breathing). (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I would worry if my child developed whooping cough (pertussis). (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree It is possible my child could get a had cut on the arm. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A3. «a. A5. A6. A7. A9. SO. 51. 52. 53. 5A. It is possible my child could get measles. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent a bad cold. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent ms. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree Inulufizflng my child will be expensive. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree Obtaining inmunizations for my child/children will take a lot of time. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I would worry if my child developed chicken pox. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent a had cut on the arm. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent measles. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could very likely prevent drinking something poisonous accidently. (l) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent whooping cough (pertussis). (l) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree It is possible my child could develop strep throat. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree It is possible my child could get chicken pox. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree 55. 56. 57. 58. 59. 60. 61. 62. 63. 6A. 65. There isn't much anyone can do about cannon childhood illnesses. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent anemia or low blood. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree A health care provider (doctor or nurse) could cure/prevent strep throat. (I) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree If my child developed strep throat I would worry. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree Immnizing my child/children will make them sick. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree If you answer "strongly agree" or "agree" to question #59, in what way do you think your child will be sick (check all that apply)? (1) sore arlieg (A) throw up (2) fever (5) convulsions (3) irritable (6) other (explain) It will be difficult for me to find transportation to take my child to the doctor/clinic. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I find it easy to call the doctors office/cl inic to make appointments. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I know where to get inmunizations for my child. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree Having an imnunization will interfere with my baby's normal activity. .(1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree I plan to buy special foods to inprove or protect my fanily's health. (1) Strongly Disagree (2) Disagree (3) Agree (A) Strongly Agree xxvii 66. 67. 68. 69. 70. During this hospitalization, have you been given any information regarding inmunizations (check one)? Yes No Do you plan to have your baby imnunized? Yes No Undecided If so, at what age? Why? If there is any reason why you don't want your baby to get inmunizations (baby shots), please list. Do you have any suggestions as to how we could help nore parents to get imnunizations (baby shots) for their children? Thank you for your time and consideration in catpleting this questionnaire. xxviii APPENDIX E Telephone Consent Dear Parent(s): If you would be willing to accept a five-minute telephone call from us in two to six months for follow-up on this study, we would appreciate having your name and telephone number. Again, all information you provide is strictly confidential. Name Telephone Number Thank you. Sincerely, Heidi Froemke, R.N. Lyn O'Connor, R.N.