A History of the Ministry of Information, 1939-46
I. INTRODUCTION
In July 1942 the Wartime Social Survey made an inquiry on the subject of Diphtheria Immunisation at the request of the Ministry of Health, The purpose of the inquiry was to obtain information which would be useful to the Ministry, and to Campaigns Division of the Ministry of Information, in conducting a publicity campaign urging parents to have their children immunised.
The inquiry was made in particular areas selected by the Ministry of Health as having relatively high and low proportions of children immunised. Samples of parents were interviewed in these areas and the results for the “good” and the “bad” areas compared.
The questions asked of parents were designed to show to what extent they were aware of the danger of diphtheria, whether they knew about immunisation, whether they had had their children immunised, and if not, what were the reasons for this. Questions were also asked about the ages at which children had been immunised, whether immunisation had been completed by a second injection, and in what ways parents had come to hear about immunisation.
During 1944 there was a drop in the number of children immunised against diphtheria, and increased efforts were made in 1945 to raise the proportion of children immunised, and particularly the proportion of young children under school age. The responsibility for immunising infants was placed on the welfare authorities, and health visitors were asked to explain to parents the advantages of immunisation. At the same time the amount of general publicity about immunisation in newspapers, on posters, on the radio, and at the cinema, was increased, and statements were published more extensively in the local press as well as being put in the national press as before.
In the summer of 1945, the Ministry of Health asked the Social Survey to make a second inquiry on the subject. This inquiry was carried out in October 1945, and this report is concerned mainly with the results of the second inquiry.
The inquiry was planned by the Social Survey in consultation with the Ministry of Health. It was decided that a national inquiry covering England and Wales would be of more use than an inquiry concentrated in particular areas such as was made before. Some of the questions included in the previous inquiry were to be asked again and some additional questions were included.
In designing the sample the areas covered in the previous inquiry were included among others, the number of interviews made in these areas being greatly reduced, but the proportion of interviews made in each of them being kept the same as before. In this way it was possible to select a national sample but to include in it a small sample which would afford a basis for comparing the results of the two inquiries wherever the questions asked were the same. This comparison is dealt with separately in Section VII.
Method
A sample of children aged under sixteen was selected from the National Registration cards and the mothers of these children were visited and interviewed. If the mother could not be found at home a substitute was taken, the substitutes, being selected from the National Register in exactly the same, way as the original sample. Details of the sampling method are given in Appendix I.
43% of the children in the sample were aged under five and 57% were aged from five to fifteen. It may be calculated from the figures given in the Monthly Digest of Statistics, Feb. 1946, that at mid 1945 about 35% of children aged under sixteen had not yet reached their fifth birthday, and thus the sample is biased to a small extent in favour of the younger age group.
In the course of their work investigators found that the registers were not completely up to date. The cards for children aged under five are however kept up to date for reasons connected with the distribution of food supplements to children in this age group. Thus all children aged under five would be included in the register but some of those aged from five to fifteen might not be. Also in some cases cards for older children who had left the district were left in the register, and if the interviewer selected one of these are would take a substitute instead. It might also be possible that the mothers of children aged under five are more frequently to be found at home than the mothers of older children.
The bias is not large enough to make any considerable difference to the results given in this report except possibly to those relating to the proportions of children immunised at different ages, and here it has been noted.
Although there are some differences in the proportions of children in different age groups who have been immunised, a rough weighting of the figures obtained to eliminate the bias did not make any significant difference to the proportion of the whole sample that had been immunised.
On introducing herself to the informant, the interviewer first explained that she was making an inquiry on behalf of the Ministry of Health. The inquiry was concerned with diphtheria, and was being made with the purpose of finding out how much parents knew of the dangers of diphtheria and whether they knew how they could safeguard their children against it.
The first two questions asked whether the mother knew how diphtheria was caused and how it could be prevented. After these two questions had been asked, a fuller explanation of the purpose of the inquiry was given. It was of course necessary to ask these questions before any mention was made of immunisation.
Mothers were then asked whether each of their children had been immunised, if the child selected from the register had been immunised, further questions were asked as to the conditions under which immunisation had been carried out; who suggested that it should be done, how old was the child when it was done, was the immunisation completed, and other questions.
If the child selected from the register had not been immunised, the mother was asked the reason for this.
The interview was concluded with some questions about publicity media, and two more questions concerned with the extent of mothers' knowledge; did they know up to what age children should be immunised,, and what was the best age for them to be immunised.
Information was also collected during the interview as to the mother’s age and education, whether her husband was at home or away from home, the economic standing of the family, etc.
The questionnaire and the instructions given to investigators are shown in Appendix II.
In this report the answers to the questions are not dealt with in the order in which they were asked. Section II deals with the incidence of immunisation in different groups, Section III with mothers’ knowledge about diphtheria, and Section IV with publicity. The answers to Questions 4 to 10, which are concerned with the conditions of immunisation, are given in Section V and the reasons why children were not immunised in Section VI. In Section VII comparison is made between the results of this inquiry and of the inquiry made in 1942.
A rather full summary of results, with a statement of the conclusions reached, is given below. As many of the results given in the main part of the report are presented in some details, and it is perhaps difficult to get an overall picture of the situation from these, it was felt that a full summary would be of more use than a short one. Short summaries are given at the end the Sections II to V.
Summary and Conclusions
Incidence of Immunisation
About 67% of children aged under sixteen had been immunised. Of children aged under five, about a half, and of children aged under two, about a fifth, had been immunised. (Table 2, p. 7).
There were no considerable differences between the proportions of children in towns and in rural districts that had been immunised. (Table 3, P. 8).
The proportion immunised was relatively low in the North of England, being about 59% as compared with 70% in other regions. (Table 5 p. 8).
Analysis by education of mother and by the economic group of the family, showed that the children of the higher education and economic groups were rather more frequently immunised than the children of the lower groups. The differences are not very great however. (Tables 5 and 6, p. 9).
Mothers’ knowledge about diphtheria
In answer to a question “Do you know how diphtheria can be prevented?”, 78% of mothers mentioned immunisation. (Table 13, p. 13).
On being asked the cause of diphtheria, 24% of mothers showed that they knew it was an infectious disease. 23% thought that diphtheria was caused by bad drains or dirt, and the remainder said they did not know or gave other answers. (Table 7, p.10)
34% of mothers knew that it was recommended that children up to the age of fifteen should be immunised, and 56% knew that the best age for immunisation was one year old or just before the first birthday, (Table 16, p. 15).
In general mothers in the higher education and economic groups were better informed about diphtheria than were mothers in the lower groups. (Table 23, p.17).
Mothers living in small towns and in the country were on the whole better informed about diphtheria than mothers living in large towns. (Table 23, p.17).
There is not much difference in the general level of knowledge in different regions though some points, are more widely known in some regions and other points in others. Although fewer children were immunised in the North than elsewhere mothers in the North knew as much about diphtheria as did mothers in other regions. (Table 23, p. 17).
More of the younger mothers and of the mothers with children under five knew the best age to have children immunised, whereas more of the older mothers and of those with older children knew that all children up to the age of fifteen should be immunised. (Table 21, p. 16),
Publicity
Mothers were asked whether they had noticed statements about diphtheria immunisation in the main publicity media.
75% had read about immunisation in newspapers or magazines, 50% had heard about it on the radio, 40% had noticed cinema publicity and 87% had seen posters. On the whole the groups with high proportions noticing publicity were the same as the groups shown by the knowledge question to be better informed, i.e the higher education and economic groups. As these groups are likely to be better informed in general than are others it is difficult to tell exactly how much publicity is responsible for their better knowledge Analyses of answers to the knowledge question by answers to the publicity questions showed that those who had noticed publicity were better informed on all points than those who had not, and that those who had noticed press publicity, and to a lesser extent those who had heard statements on the radio, were better informed than those who had only seen posters. (Tables 24, 27, 30 and 31, pp.18 to 23).
As might be expected more of those who had noticed publicity than of those who had not had had a child or children immunised. However about the same proportion of those who had only seen posters as of those who had seen statements .in the press or had heard about immunisation on the radio had had children immunised. This suggests that although the press and the radio may be more effective than posters in spreading knowledge, posters are just as effective as other media in persuading mothers to have their children immunised. (Table 28 and 29, p.21).
It may be concluded that mothers have responded to the campaign by having their children immunised whether or not they have absorbed the information given to them about diphtheria.
Cinema publicity and posters were noticed by higher proportions of those living in towns than of those living in the country. Press publicity on the other hand was noticed slightly more by those living in the country and in small towns than by those living in large towns. (Table 25, p.18).
Most types of publicity were noticed by a slightly higher proportions of mothers in London than in other regions. (Table 26, p.19).
Mothers were also asked whether they had received leaflets about immunisation from school or from the health visitor. Higher proportions of mothers in the lower education and economic groups, and of mothers living in large towns than of others, had received such leaflets. (Table 27, p.20).
The ages at which children were immunised.
The two peak ages for immunisation were one and under one and about five years old or just over, when children generally begin going to school. (Table 32, p.24).
Of immunised children aged under five, that is of children born since the Immunisation Campaign began in 1940, 81% had been immunised in their first or second year. (Table 33, p.25).
Higher proportions of the children of mothers in the higher education and economic groups than of other children had been immunised in their younger years. There is a tendency for children living in small towns and rural areas to be immunised younger than children in large towns. A rather lower proportion of children in London and in the North than of children in the Midlands and the South were immunised before they were five years old. (Table 34, 35, 36 pp.25-6).
Who suggested that children should be immunised ?
34% of immunised children were immunised at the suggestion of the school, 19% at the suggestion of a welfare clinic, and 6% and 5% at the suggestion of health visitors and doctors respectively. (Table 37, p.27).
35% of the mothers interviewed said it had been their own idea as a result of hearing about immunisation from publicity, to have their children immunised. (Table 37, p.27).
The percentage of mothers having children immunised on their own initiative was relatively high in the higher education and economic groups, and higher in small towns and in the South than elsewhere, other groups more frequently having their children immunised as a result of suggestions from some public authority. (Table 37, 38 and 39 pp.27-8).
Other conditions of immunisation
In the majority of cases less than four weeks had elapsed between the suggestion being made and agreed to and the first injection being given, and it seems therefore that there is very little delay in getting children immunised. (Table 41, p. 29).
84% of the immunised children had been immunised under the Ministry of Health’s free scheme, and 16% by private doctors at their parents’ expense. As might be expected relatively more of the mothers in the lower economic group than of those in the higher group had taken advantage of the free scheme. (Table 42, p. 29).
In 95% of cases immunisation had been completed by a second injection. This proportion is about the same in all groups including age groups. (Table 45, p.30).
In 19% of cases the arm was said to be painful after the injection. It appears however that those experiencing trouble of this sort were not deterred from having a second injection. (Table 44, p. 30).
The reasons why children were not immunised (Table 46, p.32)
28% of children who had not been immunised were considered by their mothers to be too young, and about three quarters of these children had not in fact reached their first birthday.
In 23% of cases of children not being immunised the reason given was that the mother had not had time or had “not bothered”, and in a further 4% of cases the mother said she had not heard about immunisation at all before the interviewer’s visit.
15% of mothers whose children had not been immunised said they “did not believe in it” or that it was unnecessary. A further 8% said their husbands objected, and 3% thought their children would be hurt or frightened. Positive resistances of this sort thus account altogether for 26% of cases of children being unimmunised, and they were expressed by 9% of all the mothers interviewed. Apathy or ignorance (including ignorance about age) was shown by about 12% of mothers and accounts for about 35% of cases of children not being immunised. In other cases various practical and miscellaneous reasons were given which could not be classed either as apathy or resistance, e.g. the child had already had diphtheria, the child was waiting to have the first injection, was only a few months old, etc.
General Conclusions
It appears from the results of the inquiry that the publicity campaign has to a very great extent been successful in persuading parents to have their children immunised, and in bringing to their notice the free Immunisation scheme. The proportion of children immunised was higher at the time of the inquiry than in previous years.
The majority of mothers were aware that their children could be safeguarded against diphtheria by immunisation and 81% of mothers who had one or more children who had passed their first birthday had had at least one child immunised.
The incidence of immunisation is still considerably lower in the younger than in the older age groups, but of those children born and immunised since the campaign began the great majority were immunised in their first or second year of life.
Only 1% of mothers with immunised children had experienced any difficulty in getting their children immunised. This and other results given above suggest that the scheme is working smoothly.
It is perhaps particularly noteworthy that in as many as 35% of cases children were immunised as a result of the parents' own initiative resulting from general publicity, and that a considerable amount of ignorance as to the cause of diphtheria has not prevented mothers from having their children immunised.