INSTRUCTIONS TO INVESTIGATORS

This inquiry is being made for the Ministry of Health to assist them in the publicity campaign by which they are trying to persuade parents to have their children immunised against diphtheria, and to find out how the immunisation scheme is working.

The W.S.S. carried out an inquiry on the same subject in July, 1942, and many of the questions are the same as those asked in that inquiry. The first inquiry was made in areas chosen by the Ministry of Health because they were supposed to be particularly good or bad areas as regards the proportion of children immunised. This time we are interviewing a nationally representative sample (England and Wales only), but the areas covered previously are included in smaller proportion so that interviews made in them can be sorted out and the results compared with those of the earlier inquiry.

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EXPLANATION OF PURPOSE

Your initial explanation of the purpose of the inquiry will need to be carefully worded. (a) You must be sure not to mention immunisation until you get the Question 3. (b) You must avoid saying anything which suggests that diphtheria is an infectious disease.

Your explanation should therefore be on the following lines:

“For some time the Ministry of Health has been worried about the number of children who get diphtheria. As you may know, it is a disease which children are more likely to have than adults. The Ministry is making this inquiry to find out whether parents are aware of the dangers of diphtheria, and whether they know how they can safeguard their children against it (or prevent their children from having it)”.

Try to avoid the phrase “catching diphtheria” in this explanation, as the work “catch” may suggest infection. It is better to talk about “having” or “getting’ diphtheria.

You will, of course, need to vary your explanation for different types of informant.

When you have asked the first two questions you may give a further explanation, mentioning the publicity campaign.

Question 1. “Do you know what causes diphtheria?”

This was asked in the previous inquiry and the answers received then have suggested a more useful way of classifying replies.

If the informant says that diphtheria is an infectious disease, that children catch it from one another, that it is spread by people who have it or carry the germs, ring code 2.

However, if the informant answers “germs” you must inquire further. The results of the last inquiry were ambiguous because the answer “germs” was accepted. Some people think that diphtheria is caused by drains or dirt, and it may be supposed that the germs come from these sources. You must therefore ask “How are the germs spread?” or “Where do they come from?” before classifying the answer.

Answers such as “bad sanitation”, “dirt”, are provided for. Any other positive answer should be coded 4 and written in.

Only one answer should be coded. If the informant knows that diphtheria is infectious but says that it may also be caught from bad drains, code only the correct answer.

Question 2. “Do you know how diphtheria can be prevented?”

This is to find out how many mothers know about immunisation. The question assumes that the informant believes you when you tell her (in the explanation) that diphtheria can be prevented. Code 8 is provided for a few who may be skeptical and say that it cannot be prevented.

If the answer “inoculation” or “vaccination” is given, make sure that there is no confusion between inoculation against diphtheria and inoculation against other diseases such as small-pox. In most cases this will be clear because the housewife giving this answer will have had her children immunised, or will mention the publicity campaign.

Any other positive answers that are given should be coded 9 and written in. Again only one answer should be coded.

Question 3 .

This question should be asked about all children under 16 in the family. Space is provided for nine children. Record the sex and age of each child and whether or not the child has been immunised.

Answers referring to the child whose name you have selected from the register should be recorded on the top line.

Only ring code 3 when a child has already had an injection. If the mother has applied to have the child immunised but the injection has not yet been given ring code 4.

Two injections are needed to complete immunisation, but you need not ask here whether the immunisation was completed. If a child has had one injection the answer to this question is Yes.

We are asking this question about all children so that we may know how many mothers have had all, some, or none of their children immunised, and what are the ages of the children.

Questions 4 to 11

These questions are asked only about the child whose name you have selected from the register. If the informant has had other children immunised as well, she may want to tell you about these children also. You should, of course, listen to this, but record only information about the selected child.

It may be that the selected child has not been immunised but other children in the family have. In this case you should only ask Question 11, which again refers only to the selected child.

Thus in every interview you ask either Questions 4 to 10, or Question 11.

We are confining these questions to the selected child because the selected children form a random sample of all children, and it is unnecessary to inquire about every child in the family.

Question 4

Record the age of the selected child when immunised.

Question 5. “Who suggested the child should be immunised?”

Suggestions that children should be immunised are made to individual mothers by the school authorities, by health visitors (include district 47 nurses), by Welfare clinics and by private doctors. A leaflet is generally given to the housewife together with a form to fill up.

It may be that a mother has been told about immunisation both by the health visitor and by the school. In this case you should ring the code referring to the stimulus which was finally effective, i.e. the one received last before the child was immunised.

There may be some mothers who have acted on their own initiative after seeing posters or hearing about immunisation on the radio, or from non-medical friends. Code 5 is provided for those.

If an answer to this question is not immediately forthcoming, you should prompt all the possible answers.

Question 6. (Do not prompt). “Did you have any difficulty?”

You are not asked to judge of difficulty yourself. If the mother herself considers she had difficulty, ring Yes and record what the difficulty was below. It may be any sort of difficulty, e.g. delay in being able to get the doctor or the school authorities to do it, or inconvenience of the arrangements made, such as having to take the child a long distance.

Question 7. “How long after it was suggested was the immunisation done?”

This is asked of mothers who had the child immunised at the suggestion of the school, the health visitor, the doctor or the welfare clinic.

We are not sure that it will be possible for mothers who had the child immunised a long time ago to give accurate answers. In this case ring 5 for “Don’t remember”.

The time wanted is the time that elapsed between the mother agreeing that her child should be immunised (this will be when she returned the filled-in form, if the immunisation was done under the M.O.H. scheme), and the time at which the first injection was given.

The purpose is to find out about delay (if any) in immunisation being carried out.

Question 8. “Was the immunisation completed?”

You should ask on how many occasions the child had an injection, and if the answer is two the immunisation can be coded as completed. If the child only had one injection the answer is No.

Some individual doctors give three injections, but two can be considered as complete.

It is suspected that some mothers do not take their children a second time and the purpose of this question is to find out in how many cases this is so.

Question 9.

Occasionally pain is experienced after an injection has been made. This question is to find out in how many cases this occurs and whether it results in mothers not taking their children to have a second injection, which we will know by considering the results of this and the previous question together. You will have to take the mother’s word for it as to whether the arm was painful or not.

Question 10. “Did you pay for it or have it done under the Council’s scheme?”

Some mothers prefer to have the immunisation done by their own doctors, and in this case they pay a doctor’s fee in the usual way. However, any mother may take advantage of the Ministry of Health’s immunisation scheme, which is run by the local authorities, and is free. School children are generally immunised at school and young children at the welfare clinic.

Question 11. (Do not prompt). “Why was the child not immunised?”

Only one answer should be coded. If two are given, code the more specific, or if in doubt ask which is the main reason.

e.g. “I haven’t had time yet and anyway I am waiting to consult my husband,” should be coded 6.

“I don’t believe in it. My husband disapproves” should be coded 1.

“I haven’t bothered. I don’t think it’s necessary if a child is healthy” should be coded 0.

But: “I haven’t thought about it much, but I expect I will have it done sometime”, or simply “I haven’t had time yet” should be coded X.

“I will have it done when he is older” should be coded 3.

“I don’t believe in it. H would be frightened” should be coded 2.

But: “He’s only a baby and would be frightened; I shall have it done when he’s older” should be coded 3.

If the housewife has agreed to have it done and has sent a form to the school but the immunisation has not yet been carried out, code 7.

If the housewife did not know about immunisation before you called, you should code Y. (Ask the question unless she has already made it quite clear that she knew nothing about it before).

If the informant simply says she has not thought about it at all, find out whether she had heard about immunisation. If she had not heard about it code Y; if she had heard about it but make no further answer, code “Don’t know” 9, but if any “reason” or “excuse” is offered, such as “haven’t had time”, or if she says “I supposed I had better have it done”, code X. Thus “Don’t know” should only be used when no other answer is forthcoming.

Question 12. “Have you read or heard about immunisation in any of the following ways?”

This is to find out to what extent the diphtheria publicity has reached mothers, and you should ask all except those who are coded Y in question 11.

Although immunisation is often the direct result of one of the stimuli mentioned in Question 5, other sorts of publicity may assist in causing mothers to make up their minds.

In the previous inquiry suggestions made to individual mothers (as in Question 5) were not differentiated from general publicity. In this inquiry we make a distinction between them.

Ask about each medium separately. The last “Leaflet from school, health visitor, etc.” should only be asked if not mentioned in Question 5. If 1, 2, 3 or 4 is coded in Question 5 ring 9 in Question 12 without asking again.

Question 13. “Do you know up to what age children should be immunised?

The Ministry is stressing in its publicity that all children up to the age of 15 should be immunised.

The answer “up to 14” may be counted as right. But “under 14” is wrong. If the housewife’s reply is not clear in this respect ask her whether she thinks children aged 14 should be immunised before classifying the answer.

“Until they leave school” may be counted as correct.

Up to any age above 15 may be counted as correct.

Any other answer, unless it is “Don’t know” should be counted as wrong.

Question 14. “Do you know what is the best age to have children immunised?”

The best age to have a child immunised is one year old or just before the first birthday. Either of these answers should count as right.

Any other answer, i.e. less than 10 months, or two years old or more, should be counted as wrong.

This point is being stressed in the new publicity.

Question 15. “Do you use a children’s Welfare Clinic?”

If the mother used a welfare clinic when her children were young, but does not do so now, code 4 for “used to”. If she has only visited the clinic once or twice in the last year code “occasionally”. If she has used the clinic more than this in the last year code 1.

If the clinic is only visited for the purpose of getting fruit juice or cod liver oil this should not count.

Question 16. “Have you ever been present at a school medical examination?”

Parents are invited to attend the school medical examination. If the parent has ever attended on the occasion of one of her children’s examinations code 6 for Yes.

CLASSIFICATION SECTION

Please write in town or district as given on your quota sheet. If you are working in a rural area give the name of the rural district and not the name of the parish or village in which the interview was made. Urban or Rural should be classified as given on your quota sheet: RD = Rural.

The Region number is given on you quota sheet.

Full time work = 30 hours per week or more.

The husband should count as away if he is in the Forces or working away from home and does not get back regularly for weekends etc.

Elementary education means here that the informant finished her education at a public elementary school. University or private schools can be counted as “other” code 6.

Base Economic Group on the wage rate of the chief wage earner in the family, as usual.

Ring 1 or 2 for original or substitute according to which sample list your informant is taken from.