Household Decision-making for the MenACWY Vaccination: How Parents and Adolescents Deal with an Adolescent Vaccination Decision

"...insight into how future vaccination efforts targeting adolescents can align more closely with household interactions and with those involved in the decision-making process."

In response to increases of invasive meningococcal disease (IMD) serogroup W (MenW) between 2015 and 2018, The Netherlands introduced the MenACWY vaccination into the National Immunisation Programme (NIP) in 2018 and initiated a catch-up campaign among adolescents. To guide future communication efforts, this study aimed to gain insight into the decision-making process within households regarding the MenACWY vaccination, taking perspectives of both parents and adolescents into account.

Accompanying the catch-up campaign was an extensive communication campaign designed to reach adolescents consisting of: an information pamphlet sent along with the invitation to get vaccinated from the local municipal health service, a specific website geared toward adolescents, a chat-based Q&A for adolescents to ask questions of medical professionals, and use of several influencers. Notably, of these offerings, the pamphlets sent along with the invite were the main way adolescents consumed information about MenACWY vaccination.

The study's theoretical framework is based on the Precaution Adaption Process (PAP) model, which frames behavioural change as a dynamic process. Starting from a point of being unaware about a particular issue, the PAP model theorises that people go through stages when potentially introducing a health-protective behaviour into their lives. The transitions between the stages are conceived of as barriers, with people displaying particular actions as these barriers are overcome. The stages thus emphasise the progression of thoughts and actions people go through during the decision-making process.

Using an interview guide informed by the PAP, the researchers conducted 38 semi-structured interviews in 20 households (7 not vaccinated) with 20 parents and 18 adolescents (18 dyads) across The Netherlands between April and October 2019. To include participants with a non-western migration background, 3 of the dyads were recruited with the help of the Al Amal Foundation.

The PAP model theorises that before the decision-making, people first have to become aware of an issue (passing stage 1) and then have to engage with it (passing stage 2) to proceed into the decision-making process (stage 3). The findings of the study are presented first according to the steps to get to stage 3 both for the parents and for the adolescents. Awareness of the vaccine occurred in three ways among parents: through news outlets, through conversations with others, or when the household received the invitation to get the MenACWY vaccine. Finding more information happened primarily online, through Google. For adolescents, the first stages of the PAP model cover a much shorter timeframe than with parents. For most, the awareness of both the disease and the vaccine occurred simultaneously. Furthermore, it was not a particular behaviour or action on their part that indicated they had moved into the decision-making stage; it was about their parents bringing them into the process - or not.

With regard to PAP model stage 3, the moment of receiving the invitation triggered a conversation on the topic between parent(s) and the invited adolescent among all dyads interviewed. This is the point where parents articulated the desired level of adolescent involvement in the decision. Households in the study took different approaches in involving the adolescent in the decision-making, resulting in three styles of household decision-making: parents decide without the adolescent; parents involve the adolescent (e.g., they use the invitation for MenACWY vaccination as a teachable moment and explicitly suggest the adolescent read the pamphlet and think about the topic, thus encouraging their engagement); or parents leave it up to the adolescent to decide.

In terms of PAP model stage 4 ("Decided not to act") and stage 5 ("Decided to act"), parents indicated that previously developed ideas about vaccinations, either in favour of or against, played an important role in framing their decision about MenACWY vaccination. Lasting impressions surrounding previous experiences were noted in households who knew someone who had had meningococcal disease. Adolescents who had discussed the choice with their parents echoed similar reasonings as their parents for the decision made. This finding further demonstrates the reach of the influence of parents on the adolescent in these types of decisions.

In short, parents influence adolescent reasoning, engagement, and involvement during MenACWY vaccination decision-making, and this is the case both among those who accepted and who rejected MenACWY vaccination. Adolescent engagement with MenACWY vaccination decision-making is either short-lived or non-existent, with any involvement being dependent on parental expectations and parental stimulation. ("Most adolescents in the current study appeared perfectly fine with parental influence in the matter, with several not even interested in engaging in a discussion about deciding.")

However, according to the researchers, the moment offers opportunities to engage adolescents on vaccinations and decision-making, with parents as key figures to promote this. For example:

• They could stimulate adolescent engagement with the topic of vaccinations and create opportunity to have conversations about this. Adolescents in the study often expressed a sense of autonomy and a sense of influence because of this inclusion in the decision-making process. However, all parents who took this route acknowledged that while they thought it to be important to stimulate their child to think about the topic, there was little actual influence for the adolescent to change the parental course of action.
• On the other hand, parents of adolescents who ended up not getting the vaccination did open the door to adolescent influence on the decision. Parents stated their preference up front and mostly gave the adolescent the option to choose something different. However, there was rarely any instruction given to the adolescent on how to go about making this decision for themselves. It is in these settings that more adolescent engagement with the topic could potentially make a difference.
• The legal framework surrounding self-consent for vaccinations in The Netherlands affords adolescents between 12 and 15 years old a definitive say in the matter. Strengthening adolescent awareness of their rights to self-consent could increase their engagement with the topic. (However, it might also strengthen their resolve to oppose a vaccination because of the oft-stated dislike for needles.)

In conclusion: "More research could be done to assess the Dutch situation surrounding adolescent self-consent and to determine the possible effects of promoting more direct adolescent engagement with vaccination decisions. [The] data has shown that parents currently have an influential role in the decision-making, thus parental responses and possible objections to more prominent involvement of the adolescent should be taken into account in future research efforts."