The results were categorized under three main themes, with subheadings structuring the arguments under each main theme.
Arguments in favour of receiving the BCG vaccine
Statements in favour of receiving the BCG vaccine were phrased very similar to that of the written information about the Danish Calmette Study. When focusing on the beneficial effects of the vaccine, the negative side effects were considered to have minor importance. Other favourable arguments focused on the fact that the vaccine had been used for almost 100 years without causing serious adverse events.
Stimulating the immune system
One group of arguments focused on the possible beneficial effects of the BCG vaccine on the immune system, which the participants related to concrete experiences with illness and disease in their own family:
“There has really been a lot of disease in my part of our family, so I think an augmented immune system would be beneficial in my case.”.
“What captured my interest was this idea about the immune system because I have had sinusitis twice a year. I get sick from almost anything, so this [vaccine] would definitely be interesting.”.
“... I'm a second-time mother, and when our first child started day care, he was sick all the time, so if you could do anything about that, I mean like with this vaccine, then I would definitely think it could make a difference, also in relation to quality of life when they are starting in day care.”.
These reflections focused on experiences with disease in the participants own families, including an improved quality of life when children are less sick, and problems regarding taking care of sick children when working. Parents predicted the potency of the immune system of their future child on the basis of experiences with sickness in their own family.
Atopic disease
Similarly, parents predicted the risk of their future child to suffer from asthma or eczema on the basis of experiences in their own family.
“Now I know that my husband’s allergies and asthma are heritable ... if it [the vaccine] can diminish the effect on these heritable factors, I think it would be important.”.
“No, I would not hesitate because I have both asthma, allergies and eczema. So I would, if I could, I would do everything possible for the child to avoid that. That is for certain.”.
The parents knew that allergies and asthma are heritable. They argued that if the vaccine could decrease the risk for their child to contract these disorders, despite their hereditary nature, the vaccine would be beneficial.
‘Risk of negative side effects is negligible compared to the possible benefits’
When speaking with parents about negative side effects of the BCG vaccine, some considered the risk very low compared to the possible benefits of the BCG vaccine.
“If there had been something other than these minor wounds and then one out of 1000 getting an abscess or so, that's nothing. If there had been something much worse, if you could become hemiplegic after receiving it or something crazy like that, then I think I would say no. But there isn't. It is small events, and it is treatable.”.
An old, well-established vaccine
Many statements emphasized the fact that the BCG vaccine has been used for almost a century without causing serious adverse reactions.
“I think it’s a good point, too, that it has been used for so long without any incidences; nothing serious appeared. That’s a heavy argument.”
Arguments against receiving the BCG vaccine
Parental arguments against BCG immunization mainly focused on its negative side effects; however, the scar caused by the vaccination and the fact that it might be healthier or more safe to avoid being vaccinated were also mentioned.
Concerns about side effects
Some of the participants were concerned about non-described negative side effects, and this accounted for a major part of the discussions in the focus groups. Below are a few examples:
“If it had side effects that could not be readily treated or that could cause serious injury, I would strongly consider saying no.”
“I will not risk that my baby gets Down's syndrome from a vaccine or gets some serious injury to the nervous system or something like that.”.
Some parents feared that severe negative side effects that health professionals had not considered may occur. Furthermore, the parents expressed doubts about the written information provided and asked whether there could be more side effects than those described:
“What really makes me uncomfortable is … aren’t there any more side effects than those written here? Is it then because they don’t know if there are more side effects or is it because they just want people to get the vaccine? Well, you hear so much about how you trust people and then are getting cheated in these TV programs.”
Finally, a few parents assessed the risk of the negative side effects of the vaccine differently when the vaccination was being used to achieve non-specific positive side effects rather than to protect against a severe disease.
The scar
After BCG vaccination, most children develop a small scar on their upper left arm at the vaccine injection site. Some parents mention this scar as an argument against vaccinating their children.
“The only thing that could keep me from doing this is the wound and the scar afterwards. What will it look like?”
A few parents argued that a cosmetic problem is secondary to the beneficial effect of the vaccine on the immune system, but for others, the scar was a reason for not allowing their children to be vaccinated.
It is more natural to avoid it
A few parents believe it is more natural to avoid vaccination; they implicitly understand avoiding vaccination as healthier or safer.
“I think it's more natural to avoid the vaccine, and then I just don't want to put that much into the body - medicine and that kind.”.
Decisional conflicts
Two main themes appeared in the meaning units group “decisional conflicts”: attitudes and beliefs in the parents’ network and the need for support from a health professional to make their decision.
Attitudes and beliefs in the network
Several parents stated that persons in their network having had vaccination experiences with negative side effects and the attitudes of persons in their network would greatly influence their decision about whether to allow their child to be immunized.
“If someone had bad experiences with this vaccine, of course it would affect me, especially if they were close to me.”.
“I can understand that people refuse if they have a close experience with these vaccines causing brain injury or death, but what is the risk for oneself? I don't know.”.
It is remarkable, that the closeness of the persons that had negative experiences to the parents has an impact on the parents’ decision. Additionally, it seems that the African research described in the written information from the Danish Calmette Study was considered less important.
“Research from developing countries, that's kind of far away. We need something closer.”.
Help from a health professional to make a decision
When asked what would be crucial for making a decision, several parents stated that they needed to talk with a health-professional.
“From what is written here I don't think the side effects are something to worry about, but I would definitely ask more about it before I could make a decision. And then I would ask about experiences.”.
A father in one of the focus groups read the written information about the negative side effects of the BCG vaccine and replied as follows:
“What is meant by ‘one in 1000’? I don’t know if my child will be the one or one of the 999.”.