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Evaluation of the MMR discussion pack and preparation of the MMR communication strategy

Summary

Background to the study

The Health Education Board for Scotland, (HEBS), now “NHS Health Scotland”, has a key role in the development of resources for parents and health professionals to support the child immunisation programme and has been at the forefront of efforts to promote MMR.  This role has been particularly emphasised following the publication in 1998 of a short report in The Lancet that suggested that the Measles, Mumps and Rubella triple vaccine (MMR) might be linked to developmental regression and bowel disorder (Wakefield et al, 1998). 

The position of the broad majority of the medical and scientific community has been consistent: that the vaccine is the safest way to protect children against measles, mumps and rubella; and that alternative vaccinating regimes would not provide the level of protection afforded by the triple vaccine.  There is now a considerable body of evidence to refute Wakefield’s assertions, but the controversy surrounding MMR has continued.  It is now believed that the adverse publicity generated by Wakefield’s claims has contributed to a decline in uptake of MMR to a point where, in some areas, herd immunity may have been compromised.

Aims of the study

The research had three specific aims:

• To evaluate the MMR Discussion Pack and the MMR leaflet (MMR – Your Questions Answered)  in terms of the reasons for, and means of, use by parents and health professionals.
• To establish whether and how health professionals gain access to the MMR Discussion Pack
• To explore the needs of health professionals and parents regarding the communication issues surrounding the MMR vaccine, and to establish how these can best be addressed.

Research design and methods

The study employed a multi-method research design to explore the views of parents and health professionals. The research was conducted across Scotland and comprised:

• Postal surveys of large representative samples of parents of infants aged 6 – 18 months, and primary care and public health care professionals
• Focus group discussions with parents and health professionals
• Interviews with parents and health professionals.

 

Parents’ perspectives

• While the vast majority of parents had no concerns about most routine child immunisations, only a quarter of survey respondents were wholly confident about MMR:  a quarter expressed “serious” concerns about the vaccine, a five-fold increase compared with opinions in 1998
• 4 in 5 parents of a child eligible for MMR (aged 12 months+) had either already had MMR, or intended to accept the vaccine.  Many parents remained undecided about MMR, but only 7% of parents overall did not intend to accept the vaccine. 
• There was a clear association between opinions about MMR and behavioural intentions, with a quarter of those with “serious” concerns intending to reject MMR. As children approached the age at which MMR is offered, parents appeared to become both more decisive and more likely to accept the vaccine.
• Exposure to written materials about MMR and/or discussions with health professionals, (“MMR Contacts”), had a positive impact on parents’ decision-making: uncertainty was reduced amongst exposed parents and there was a greater likelihood of a decision to accept MMR.
• “MMR Contacts” were particularly effective amongst those parents with moderate concerns (who represent half of all parents), and for parents whose child was old enough to receive MMR.  Contacts at earlier ages were less influential.

Health professionals’ perspectives

• The vast majority of health professionals had no reservations about MMR. A quarter of the public health professional respondents, a third of the GPs and half of the Health Visitors, while still supportive of MMR and believing it to be “on balance a good thing”, expressed some concerns about the vaccine.  Very few however had serious worries and none reported awareness, or professional experience, of any adverse responses to the vaccine within their own practice.
• Levels of concern about MMR amongst health professionals were closely associated with a number of factors related to health professionals’ perceptions of their own professional practice and self-efficacy:

- Health professionals who regarded MMR as a safe vaccination were more likely than those with concerns to feel adequately informed about MMR, and to be more positive about their MMR-related work with parents

- Health professionals with concerns about MMR were less likely to rate MMR written resources as helpful, and felt themselves to have greater support needs for their MMR-related work with parents

- Similarly, “MMR confident” health professionals were more likely to feel informed about MMR and that their discussions with parents were helpful.

MMR Resources

MMR: Your Questions Answered

• Two-thirds of parents who had received an invitation for MMR, had seen the leaflet “MMR: Your Questions Answered”.
• Of those who had seen the leaflet, half felt that it gave them all the information wanted, and 5 in 6 regarded it to have been useful.

The MMR Discussion Pack

• Overall, only one in eight of all parents knew about the MMR Discussion Pack, and even fewer – 1 in 12 - had actually had an opportunity to look at or read it
• Of those who had seen the Pack, almost three quarters felt that it gave either all or some of the information they wanted, and only one in eight parents felt that it did not give them any of the information they wanted 
• Parents who were dissatisfied with the amount of information in the leaflet were no more likely to have seen the Pack than other parents, suggesting that they had not been directed to it by health professionals, as a further source of information.
• The MMR Discussion Pack was often used to inform discussions with parents as well as serving as a resource for health professionals’ own information needs
• Two-thirds of primary care health professionals regarded the Pack as a “very useful” resource for health professionals
• The most often requested improvement to the Pack was that there should be a summary version which could be made more easily available to parents who wanted more information

Discussion with health professionals

• Three-quarters of all parents had discussed MMR with a primary care health professional
• A third of those having discussions with health professionals had already made a decision about MMR, and for the vast majority (88%) it was to accept MMR
• Access to any NHS-based MMR resources - be it the leaflet, the Discussion Pack and/or a discussion with a health professional - was associated with less indecision on the part of parents and an increased likelihood of having or intending to accept MMR.

Implications for HEBS MMR communication strategy

Since the controversy about the vaccine in 1998, HEBS strategy in relation to MMR has been characterised by a need to address parents’ and health professionals’ information and support needs.   

• The MMR Discussion Pack exactly meets the information needs of many health professionals and has clearly assisted them in their work with parents
• The production of the Pack in a range of formats and, especially, a version that could be distributed to all those parents who want more information would be welcomed by health professionals
• Confident, knowledgeable and informed health professionals are those best positioned to support parents
• Supporting health professionals to present themselves as “supportive advocates”, is likely to yield positive results in terms of uptake of the vaccine.  This support should include:

- Additional attempts to address health professionals’ own concerns about MMR
- Specific interventions and training to promote immunisation advocacy and communication skills.

1. Introduction

1.1 Background to the study

The Measles, Mumps and Rubella triple vaccine  (MMR) is routinely offered to children aged 12 – 15 months with a second dose offered at 3 – 5 years. In 1998, Andrew Wakefield and colleagues suggested that the vaccine might be linked to developmental regression and bowel disorder (Wakefield et al, 1998).  The controversy surrounding the report, published in The Lancet, has been aired at length in the media and, it is believed, has contributed to a decline in uptake of MMR.  In some areas of the UK, there is now concern that uptake may not be adequate to maintain herd immunity in the population. 

Studies based on large cohorts of children in Scandinavia, the UK and the USA have all concluded that MMR is not associated with an increased incidence of autism (Madsen et al, 2002; Hultman et al, 2002; Kaye et al, 2001; Dales et al, 2001).  There is no evidence of a temporal association between MMR and a diagnosis of autism or Asperger’s Syndrome or the reporting of parental concerns (Taylor et al, 1999).  Furthermore, there is no evidence to suggest that MMR is linked to the development of any new variant of the disorder (Frombonne et al, 2001).  There is considerable debate, however, whether there has even been a real increase in the prevalence of autism.  The most recent evidence suggests that changing diagnostic thresholds, better and more active case ascertainment, survival, population flows, and changes in the prevalence of causal factors may have suggested an apparent increase in autism, and that we have simply become better at recognising the disorder (MRC Review of Autism Research, 2001). 

The position of the medical and scientific community has been consistent: namely, that the vaccine is the safest way to protect children against measles, mumps and rubella and that alternative vaccinating regimes (for example, single vaccines) would not provide the level of protection afforded by the triple vaccine. 

The MMR Expert Group, which included representatives from a wide range of organisations and interests, was convened by the Scottish Executive in response to a report by the Health and Community Care Committee of the Scottish Parliament.  Its deliberations came to the same conclusions (Report of the MMR Expert Group, 2002).  This position has been maintained by the government and underlies its advice to parents.

The Health Education Board for Scotland (HEBS)¹ has a key role in the development of resources for parents and health professionals to support the child immunisation programme and has been at the forefront of efforts to promote MMR.  HEBS has commissioned research to inform its immunisation communication strategy, including qualitative research to explore parents’ opinions about MMR (1998), an evaluation of the communication strategy for the MenC programme (2001), and research which has considered broader issues surrounding parental decision-making in relation to child immunisation (2001)².

These studies have documented parents’ concerns and confusion, but have also highlighted the difficulties health professionals face when working with parents to promote uptake of MMR.  The largely qualitative research suggested that many front-line health professionals were both ambiguous and ambivalent about their role as active promoters of MMR.  It was clear, however, that parents looked to trusted health professionals for advice about MMR and may be discouraged from accepting the vaccine if they believe that these professionals are, themselves, less than wholly confident about MMR.

HEBS has produced a range of materials and resources for parents and health professionals – including, most recently, The MMR Discussion Pack and a new MMR leaflet - “MMR – your questions answered” - for parents.  The MMR Discussion Pack was first distributed in 2001 to all general practices, and is currently provided to health professionals – particularly to GPs and health visitors - to inform and facilitate discussion with parents.  The supplementary leaflet that accompanies the Pack, “MMR your questions answered” is intended to be provided to parents at the same time as the invitation to attend for MMR. 

Following the initial distribution of the Pack and leaflet there is a need, highlighted by the MMR Expert Group, to evaluate whether these resources adequately meet the needs of health professionals and parents alike.  Beyond that, research is also required to inform HEBS communication strategy for MMR more generally to ensure that the information and support needs of health professionals and parents are appropriately addressed.

The research reported here had two parallel strands: the first explored parents’ views about MMR; their intentions in relation to the vaccine; perceptions of their information and support needs; and perceptions of how well these needs are met by current resources (including the MMR Discussion Pack and Leaflet) and contacts with health professionals.  The second strand focused on the experiences and needs of primary and public health professionals; their opinions of MMR; perceptions of their own MMR-related professional practice; and on their views of the key resources. 

The study was carried out across Scotland and comprised both quantitative survey and qualitative elements.  Ethical approval to use the Standard Immunisation and Recall System (SIRS) and Community Health Index (CHI) databases to obtain the parent sample was obtained from the Multi-Centre Research Ethics Committee (MREC Scotland).

¹ Now known as NHS Health Scotland (NHSHS)

² These reports are available at: www.hebs.com/research/cr

1.2 Aims and objectives of the study

The research had three specific aims

• To establish whether and how health professionals gain access to the MMR Discussion Pack and leaflets
• To evaluate the MMR Discussion Pack and leaflets in terms of the reasons for and means of use by parents and health professionals
• To explore the needs of health professionals and parents regarding the communication issues surrounding the MMR vaccine and to establish how these can best be met

1.3 Structure of the report

• Chapter 2 outlines the research design and methods
• Chapter 3 presents findings from the survey and qualitative studies of parents in relation to their opinions and decisions about MMR
• Chapter 4 considers the perspectives of health professionals and explores the factors which influence professional practice
• Chapter 5 considers the implications of the findings for HEBS communication strategy in relation to MMR

There are a number of Appendices:

Chapter 6:         Appendix A:      The parent survey data – all frequencies

Chapter 7:         Appendix B:      The health professional survey data – all frequencies

Chapter 8:         Appendix C:      MMR Discussion Pack & Leaflet data

1.4 References cited

Dales, L. et al (2001) Time trends in autism and in MMR immunization coverage in California. JAMA 285: 1183-1185

Frombonne, E. and Chakrabati, S (2001) No evidence for a new variant of Measles-Mumps-Rubella-induced autism. Pediatrics 108: 58

Hultman, C.M. et al (2002) Perinatal risk factors for infantile autism. Epidemiology  13: 417-423.

Kaye, J.A. et al (2001) Mumps, measles, and rubella vaccine and the incidence of autism recorded by general practitioners: a time trend survey. BMJ  322: 460-463.

Madsen, K.M. et al (2002) A population-based study of measles, mumps and rubella vaccination and autism. New England Journal of Medicine  347: 1477-1482

Martin, C.J. et al (1998) Parents’ opinions about MMR. Final Report to HEBS

Martin, C.J. et al (2001) Developmental research to inform HEBS immunisation strategy. Final Report to HEBS

Report of the MMR Expert Group (2002), Health and Community Care Committee, Scottish Executive: Edinburgh

Taylor, B. et al (1999) Autism and measles, mumps and rubella vaccine: no epidemiological evidence for a causal association. Lancet, 353, 2026 - 9

Wakefield, A.J. et al (1998) Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 351: 637-641.

2. Research design and methods

The views of parents and primary care and public health professionals were explored through self-completion postal surveys, focus group discussions and interviews.

2.1 The postal surveys

Postal surveys of parents, primary care and public health professionals were conducted during July and August 2002.  Ethical approval to access the SIRS databases was obtained following submission to MREC Scotland.

Although each of the three survey instruments for parents, primary care health professionals and public health professionals, respectively, focused on issues relevant for the sample population, there were a number of common questions asked of all parent and health professional respondents in relation to opinions about routine child vaccinations.  The questionnaires were wholly structured with pre-coded response categories, but each had space at the end for additional comments.  The parent and primary care questionnaires also included a consent form to be completed if the respondent was willing to participate further in the research by taking part in a focus group discussion or interview.  Reminders were sent to all those sampled, 2 – 3 weeks after the initial mailing.  (Copies of the questionnaires © can be obtained from Scottish Health Feedback).

2.1.1 The parent sample

A questionnaire about child immunisation was sent to a random probability proportional sample of 5231 parents of children born in 2001 in Scotland (defined as births occurring between 01 January 2001 and 31 December 2001 inclusive).  The sample was drawn from the Community Health Index (CHI) and cross-checked with the Standard Immunisation & Recall System (SIRS) held by health boards.  The Grampian Immunisation Recall System (GIRS) was used for births in Grampian.  The samples for areas with a small number of births (Orkney, Shetland and the Western Isles) were boosted to 100 each to ensure that there was adequate representation of parents living in these areas.  The sampling process was co-ordinated centrally by SEMA, (a supplier of IT consulting, systems integration, and network and infrastructure services to the public and other sectors) in Edinburgh.  (Table 0‑21 and Table 0‑22 in Chapter 6 - Appendix A provide details of the distribution of mailed and completed questionnaires by health board area). 

The Directors of Public Health for each health board area co-operated fully in the study by allowing access to the relevant databases, and each provided a letter of support to accompany the questionnaires sent to parents in their area.  Completed questionnaires were returned to Scottish Health Feedback using an enclosed Freepost envelope.

2.1.2 The primary care and public health professional samples

The study targeted primary care health professionals most likely to have a role in relation to the delivery of routine child immunisation - General Practitioners, Practice Nurses and Health Visitors. 

All health visitors in Scotland were invited to take part in the study.  A random sample of 204 general practices was selected from all practices in Scotland, with a GP and a Practice Nurse within each to be included in the survey. In all, 2009 primary care health professionals were included in the survey sample (see Table 0‑26 in chapter 7: Appendix B).

Health visitors were recruited through the lead health visitors within each LHCC, who agreed to distribute the questionnaires to all health visitors within the locality.  A total of 1601 health visitors should have received a questionnaire in this way.

Two questionnaires were sent to the Practice Manager for each randomly selected GP practice, with a letter asking that one of the questionnaires be directed towards a (or the) GP with lead responsibility for immunisation, and one to the Practice Nurse.

The public health sample comprised all Public Health Practitioners (N=83), Immunisation Co-ordinators (N=15), a random sample of (other) Public Health Consultants (N=99), and a random sample of Community Paediatricians (N=26). Table 0‑25 in Appendix C/chapter 8 provides details of the mailing and achieved sample.

2.1.3 The questionnaires

The questionnaire packs for parents included, as well as the questionnaire, a letter from the research team describing the study, a letter from the Director of Public Health for their area, an information sheet, which gave further details of the study and contact details for SHF and for HEBS, and a freepost envelope for the return of questionnaires. 

The parent questionnaire was presented as an A4 5-page booklet, the last page of which comprised a consent form, which asked parents if they would be willing to be further involved in the study.  If so, respondents were asked to give their signed consent and to provide contact details.  

The parent questionnaire covered the following issues

• the immunisation history for the survey infant
• opinions about routine child immunisations
• perceptions of adequacy of information about vaccinations other than MMR
• awareness of HEBS written resources  (the MMR Leaflet & Discussion Pack) and perceptions of the usefulness of these resources
• contacts with health professionals about MMR and perceptions of the usefulness of these contacts
• whether their child had already had MMR or whether they intended  to accept the vaccine

Reminder letters were sent, using the same channels as for the initial mailing, to the entire sample two to three weeks after the initial mailing.

The questionnaire sent to primary care professionals was presented as an A4 8- page booklet.  This was rather longer than the questionnaire sent to public health professionals.  Both schedules, however, included questions relating to health professionals' views and experiences of child immunisation work in general, and of MMR in particular.  While the primary care questionnaire focused more on interactions with parents, there was a greater emphasis in the public health professionals’ questionnaire on interactions with other health professionals.

The health professionals’ questionnaires covered the following issues:

• health professionals’ immunisation activities
• opinions about child immunisations (the same questions were used across all parent and professional samples)
• awareness, use of and perceptions of MMR resources
• experiences of responding to parents'/health professionals’ information and support needs
• perceptions of own practice in relation to MMR
• perceptions of own information and support needs in relation to MMR
• perceptions of current and ideal immunisation roles

The content of the questionnaires was informed, to a large extent, by the earlier qualitative research conducted by Scottish Health Feedback in 1998 and 2001.

2.1.4 Response rates and sample characteristics

The parent sample

Questionnaires were sent to a random probability proportional sample of parents of infants born between 1^st January and 31^st December 2001 and, therefore, aged between 6 and 18 months at the time of the initial mailing. In all, 2142 questionnaires were returned, giving an overall response rate of 41%.  Of those who responded, 44% consented to be further involved in the study through participation in a discussion group or individual interview (See Section 2.2).  The immunising profile of all those who responded to the survey suggests that, as a whole, the sample was similar to the general population of parents (see below). 

Table 2.1: Proportion of children vaccinated against DTP, Polio, Hib and MenC: Comparison of survey and national data

Vaccine	From survey *	National data **
Diphtheria	96%	95.8%
Tetanus	95%	95.8%
Polio	98%	95.8%
Pertussis	93%	95.5%
Hib	91%	95.5%
MenC	89%	94.5%
N=100%	2142	13399

* Uptake rates from survey: % coverage at 6 - 20 months; **Primary immunisation uptake rates: % coverage at 12 months (births July – Sept 2001 at  September 2002): Source: ISD  November 2002

The ages of the survey children at the point of questionnaire completion ranged from 6 - 20 months, with a median age of 13 months. Figure 2‑1 shows the distribution of the ages of the children whose parents completed the questionnaire. (See also Table 0‑1 in Appendix A).

Figure 2‑1: Age of the survey baby (Months)

Just over half of all respondents (54%) added a written-in comment and these were fully transcribed and analysed.  Parents with MMR concerns – especially those with “serious concerns” - were significantly more likely to add a comment than those who did not express worries: 75% with serious concerns added a comment compared with 36% of those with no concerns about MMR. Parents with “serious concerns” represented 27% of all respondents, but 37% of all those who added a written comment (see Table 0‑19 and Table 0‑20).

Health professionals

Fifty-six percent of the health visitors (N=898) returned a completed questionnaire and just over a third (37%) of general practitioners (N=76) did so.  Although only 34 of a possible 204 practice nurses returned a questionnaire, we were informed by a number of practices that not all practice nurses have an involvement in immunisation matters and therefore questionnaires were frequently not completed.  Just over half (52%) of the public health professionals returned a questionnaire. Response rates varied by health board from 38% (Orkney) to 63% (Fife): see Table 0‑26, Table 0‑27, and Table 0‑25.

2.2 The focus groups and interviews

2.2.1 Recruitment of parents to focus groups/interviews

Participants to the parent focus groups and interviews were drawn from those who had indicated, by competing a consent form, that they wished to take part in further research.  Eight focus groups were convened in three health board areas, selected to represent a range with respect to area type (rural, semi-rural, urban) and socio-economic characteristics (deprived, affluent). 

Consenting respondents were contacted by letter and invited to attend a group at a given time and date.  The groups attempted to bring together homogenous categories of parents defined in terms of their MMR intentions or behaviour.  We did this to minimise the potential for hostile discussions between parents where the views of parents with particular views or intentions might dominate (or, indeed, intimidate) discussions.  Parents who had indicated within their questionnaire responses that they did not intend to accept MMR were brought together as one distinct group, and were not included with parents who intended to accept MMR or who were undecided about the vaccine.

Parents were offered crèche facilities for daytime groups and reimbursement of childcare costs for evening groups.  Travelling expenses were paid in full.  The groups were held in central locations. The aim had been to have groups comprising six to eight parents apiece.  Despite the efforts to encourage participation, most groups comprised fewer people than intended. In all, only 20 parents actually took part in the 6 focus groups.

The interviews with parents were conducted by telephone and targeted those who lived in remote areas of the country or who, in their questionnaire comments, had highlighted very specific concerns about MMR related to their child’s or family history.  A total of 21 interviews with parents were conducted, across all areas of the country.

2.2.2 Recruitment of health professionals to focus groups/interviews

Primary (but not public health) health care professionals were also asked if they would be willing to take part in a focus group or interview and, if so, to compete a consent form: 17% completed a consent form.  In all, eight focus groups with health visitors were convened in eight health board areas.  Participants were largely recruited from amongst those who had consented and were convened in consultation and with the support of the eight Primary Care Trusts.  Thirty health visitors, in total, participated in the 8 focus groups.  In addition, 10 telephone interviews were conducted with general practitioners.

2.2.3 Characteristics of the consenting focus group/interview samples

Those who put themselves forward for focus groups were more likely to have “concerns” about MMR: they were somewhat more likely to have “serious” concerns about MMR (34% vs. 22%) but were not more likely, overall, to have concerns about the vaccine (77% of those who consented had “some” or “serious” concerns compared with 76% of those who did not fill in the form); they were also less likely to have had MMR or to intend to do so than the other parents (63% vs. 75%).

Postcode of residence information was available for those who provided contact details (but, not for respondents who did not wish to be further involved in the research).  The Carstairs Deprivation Category (DEPCAT) profile of those who agreed to research follow up was broadly identical to the profile for Scotland as a whole (See Table 0‑24).

While the data was gathered in the course of the parent focus groups is of interest, its value and validity must be diminished by the low “turnout” and biases within the sample.  We therefore, have used the qualitative data throughout the report to illustrate points derived from the survey data. 

2.2.4 Content of discussion/interviews with parents and health professionals

Four of the group discussions with parents and four with health professionals focused specifically on the MMR Leaflet and Discussion Pack.  Parent participants were sent a copy of each in advance of the group and health professional participants were offered a copy if they had not already seen it. 

These groups considered:

• awareness of and access to both the Leaflet and Pack
• perceptions of the usefulness, completeness, readability, presentation and relevance of the information within the leaflet & pack
• assessment of whether and how access to leaflet & pack had or might have influenced parents’ decisions
• perceptions of the source[s] of information, and impact on opinions and decision-making
• access to and use of other information resources & perceptions of usefulness; and, information and support needs in relation to MMR. 

For professionals, the discussions also covered:

• how they used these resources
• perceptions of the impact of the resources on their own practice
• perceptions of the effectiveness of their discussions with parents about MMR. 

The remaining focus groups addressed wider issues relating to MMR, but the emphasis throughout was on communication between professionals and parents and on parents’ and professionals’ respective information and support needs. 

Topics included, for parents:

• perceptions of the MMR leaflet
• what they were seeking from resources and discussions with health professionals
• barriers to discussions with health professionals
• what impact access to written resources and interactions with professionals had on their own decision-making
• other sources of information about MMR

The groups and interviews with health professionals explored:

• perceptions of the MMR leaflet and Discussion Pack
• experiences with parents and perceptions of knowledge, confidence and effectiveness
• perceptions of their information, training and support needs.

2.3 Data analysis

The analysis of the qualitative data was supported by a software package (QSR “N6”).  N6 has powerful cross-referencing and indexing operations, which facilitate systematic in-depth analysis.  Firstly, the focus group, interview and written-in comments were fully transcribed.   Each was coded to reflect a number of basic characteristics of respondents: whether they were parents or professional (and professional discipline); the type of data  (i.e. focus group, interview or written-in comment); the health board area of residence; and, for the parents’ written-in comments, their current MMR intentions (i.e. child has already had MMR or intend to; does not intend to accept MMR; undecided). 

Second, we identified key concepts, which were felt to be at the core of the research. These included: concerns about MMR; information about MMR; decision-making; communication between parents and health professionals; intra-professional communication; and, information and support needs.  These were posited as primary coding categories.  The data was then coded further; either new categories which emerged from the data were developed, or existing categories were further refined and elaborated. 

The survey data were analysed using SPSS (version 11).  Where appropriate, statistical analysis to explore differences between groups or categories, have been carried out.  Differences beyond the probability level 0.05 are regarded as statistically significant.

Frequency data relating to all of the questions asked in each of the three surveys are provided in Appendices A – C (Chapters 6 – 8).

3. Parents' opinions, decisions and behaviour

3.1 Routine child immunisation

The majority of parents who took part in the survey had accepted the phalanx of routine immunisations offered in the first year.  The vaccination rates amongst the achieved sample was broadly similar to the uptake rates for Scotland as a whole (see Section 2.1.4). ³

Parents were then asked their opinion of each of these routine vaccinations and MMR.  The same questions were also asked of health professionals and replicates the MMR opinion question used the 1998 survey.⁴ 

The response options in relation to each vaccine were:

• I have no reservations – I think it is a good thing
• On balance I think it is good, but I have some concerns
• I have serious concerns about it
• I have no opinion about it

The majority of parents had been happy to accept the routine vaccinations against Diphtheria, Tetanus, Whooping Cough (Pertussis), Polio, Hib and MenC (see Table 1), with approximately 4 in 5 reporting that they had “no reservations” about any of these vaccines. (see Table 3‑1). 

Table 3‑1: Parents’ concerns about routine vaccinations

Vaccine	No reservations	100%=
Diphtheria	83%	2076
Tetanus	85%	2074
Polio	85%	2089
Whooping cough	81%	2069
Hib	82%	2056
MenC	79%	2041

Two-thirds felt that they had been given adequate information about these vaccines and a further 1 in 10 (9%) had not wanted any (more) information.  Almost a quarter, however, would have liked more information (see Table 0-3).

³ The national data are based on uptake at 24 months and it is possible that the survey data slightly underestimate the vaccination profile of the sample.  It is also possible that the slightly lower vaccination uptake rate in this sample reflects a small bias against vaccination amongst those who took part in the survey.  In addition, for Hib and MenC in particular, almost 1 in 12 parents appeared to be unsure whether their child had been vaccinated (see Tables A2a-f).

⁴ Martin CJ et al (1998) Parents’ opinions about MMR.  Final Report to HEBS.

3.2 Concerns about MMR

A very different picture, however, was found in relation to MMR with only a quarter of parents reporting that they had “no reservations”.  Half of the respondents expressed that they had “some” and a quarter that they had “serious concerns” about MMR.  The proportion of parents with any concerns has increased substantially compared with the data collected using the same question in 1998, but perhaps the most notable change is in the rate of reported “serious” concerns, which have increased five-fold over the four year period from 5% in 1998 to 27% in 2002  (see Table 3‑2). 

As like all mothers with babies due to have this jag, I have a lot of reservations.  I have seen children, which sadly suffer from autism and to be quite honest, I would never forgive myself if my daughter contracted autism through the MMR jag.  (Parent: Written Comment)

Table 3‑2: Parents’ concerns about MMR (all ages): 1998 vs. 2002

Concerns about MMR	2002 data	1998 data
No concerns	22%	40%
Some concerns	50%	52%
Serious concerns	27%	5%
No opinion	1%	3%
N=100%	2108	1237

Parental concerns about MMR are less pronounced amongst those with older infants and appear to become more positive (or, perhaps, it might be more accurate to say – less negative) as the time approaches for their child to be vaccinated, (see Figure 3‑1 for a chart of “serious concerns” by age and cohort, and Table 025).  

Figure 3‑1.   Serious concerns about MMR by current age of child (1998 and 2002)

Parents’ concerns about MMR focus, almost wholly, on the perceived risk that there may be a link between MMR and autism.  As in the previous qualitative research we have conducted, there continues to be outrage about the perceived “lack of choice” in relation to single vaccines.  There is a prevailing narrative that choices are being denied, information about the adverse effects of MMR is being withheld, the triple vaccine “overloads” the immune system, that the government cannot be trusted because of the BSE crisis, and that MMR is promoted simply in order to contain costs.

If the MMR vaccines were given separately, I don't think I would have as many concerns with getting my daughter vaccinated.  With regards to the MMR and it being linked to autism and other illnesses, I believe there is no smoke without fire.  I also believe the Government are putting Health Service costs before children's health. (Parent: Written Comment)

I do have serious concerns about my son receiving the MMR vaccine.  I feel there have been too many cases of autism linked to this vaccine and for the Government to dismiss parents concerns and not offer single vaccinations when so many children are not being immunised is simply disgusting.  My son will get the MMR but I personally feel bullied into it through lack of choice over receiving separate injections and through the fear of my son catching a possibly life threatening illness. (Parent: Written Comment)

I personally feel that the triple vaccine is too much in many circumstances for a young immune system to cope with and that autism and Crohn's Disease are merely the tip of the iceberg!  I will not be getting MMR for my child but would like the option of three separate immunisations and boosters.  Removing availability of the Rubella vaccine is very like blackmail!  (Parent: Written Comment)

To some extent, perhaps, parents’ focus on singe vaccines has become an alternative to making a decision to accept or decline the vaccine:

I would prefer it if my baby could have the MMR jags separately and not the three in one because I'm not too sure about it and have serious reservations about it and am not sure about my baby having it.  (Parent: Written Comment)

  I do have quite a few concerns relating to it, to the point where I am confused as to what decision I am going to make.  I feel that all parents whom are in this situation should have a choice as to how they would like their child immunised i.e., single vaccinations, as I for one strongly feel this should be made available as an option.  (Parent: Written Comment)

While parents may acknowledge that many studies do not support the view of a link between MMR and adverse reactions, they struggle to accept this and instead seem to want research which “proves” that there is no link with autism or Crohn’s Disease and, indeed, that there are no risks whatsoever associated with MMR.

I do realise not having the jag at all is very dangerous but until we can be told 100 percent this isn't a cause, no amount of surveys, discussions will ever change any parents’ worries, that comes from the heart.  (Parent: Written comment)

  I have no intention of getting my son immunised with MMR, until it is proved to be 100 percent safe I will not be having it done.  (Parent: Written comment)

… I feel as if we (the public) are not being told all the facts about this injection.  I love my son very much and if I knew for an absolute fact that the MMR was safe then no problems, he would have it done but I am not going to put my son's well being at risk.  He is not going to have any serious problems with getting Measles, Mumps or German Measles, some kids might have problems with these diseases but I believe these kids are already unwell or frail in some way.  I do not want to get my baby this inoculation when it might ruin his wee life forever.  If the Government can tell me that my son, without doubt, would not take autism or some kind of bowel problems by taking the MMR then he would get the jag but until then, he is too precious for me to take that risk.   (Parent: Written comment)

One respondent believed strongly that a friend’s child has been MMR-damaged, but this was the only such account from the survey – that is, which claimed a perceived link between MMR and developmental regression/autism.  There were a number of accounts of possibly adverse reactions to the vaccine including, for example, a case of febrile convulsions a few days post-vaccination.  Other respondents were concerned about measles-type reactions.  Some parents recounted family histories of autism or brain damage, which made them more anxious in case there was a familial/genetic “susceptibility” factor.

…but when you read the tabloids, heart-rending stories you start to become anxious. But the biggest reason I didn't do it is because my nephew, my sister's boy.....He's been diagnosed as being on just the edge of the spectrum of autism and there's an argument to say it's maybe an inherited thing and all the rest. … and I just decided I'd rather give him the single vaccination…… But when I see the stress it's caused my sister's family, I don't particularly want to take the risk with my second son because if something happened I would hold myself entirely responsible, knowing that there's already a child with an autism diagnosis in the family.  (Parent, focus group)

3.3 MMR intentions and behaviour

In the 1998 survey, there was a clear relation between opinions about MMR and vaccinating behaviour.  While the vast majority of parents with no concerns or “some” concerns about MMR went on to vaccinate, those with serious concerns were much less likely to do so.  For the 2002 survey, we added in questions about MMR “intentions” in order to explore the relationship between opinions and behaviour in more detail. In the 2002 survey, two-thirds (67%) of parents with a child aged 12 months or older had received an invitation for MMR.  By the time infants are 13 months or older, three-quarters (76%) had received an invitation. 

Overall, more than four in five parents of children aged 12 months or more reported that their child had either already had MMR or that they intended to do so.  Only 7% of respondents indicated that they had not had and did not intend to accept MMR: this figure is constant for those with younger and older infants.  Almost 1 in 7 (15%) of parents with a child of aged 12 months or more was undecided (at the point of the survey) about whether to have MMR (Table 3‑3 ).

Table 3‑3:  MMR intentions by current age of child

Reported MMR behaviour or intention	Age of child
	Less than 12 months	12+ months
Has already had MMR or intends to have MMR	56%	79%
Does not intend to have MMR	7%	7%
Has not decided	38%	15%
N=100%	754	1338

X²=150.1, df=2, p<0.0001

Figure 3-2 shows intentions by age in more detail.

Figure 3‑2:  MMR intentions/behaviour by current age of child

There is, as might be expected, a clear relationship between opinions about MMR and vaccinating behaviour and intentions.  Almost all of the parents who regarded MMR as a “good thing” had either already had their child vaccinated or intended to do so.  Four in five (82%) of those who had “some” concerns also had already had or intended to vaccinate.  However, only 1 in 4 (27%) who had “serious” concerns had vaccinated or intended to vaccinate and a similar proportion (23%) did not intend to vaccinate.  Those with concerns – especially those with “serious” concerns - are significantly less likely than those with no reservations to report that they do not intend to vaccinate (X²=203, df=2, p<0.0001).  Moreover, it is uncertainty rather than rejection of the vaccine which is particularly pronounced amongst those with concerns: half of those with “serious” concerns and almost 1 in 5 of those with some concerns (compared with only 2% of those with no reservations) were undecided at the time of the survey about whether to accept MMR (Table 3‑4).  

Table 3‑4: Level of concern and behavioural intention

MMR behaviour or intentions	Level of concern about MMR				All
	No concerns	Some concerns	Serious concerns	No opinion
Had MMR or intend to	98%	82%	23%	(64%)	71%
Not had MMR and does not intend to	<1%	<1%	27%	(5%)	7%
Not had MMR and not sure	2%	18%	50%	(32%)	23%
N=100%	445	1015	542	(22)	2024

The parents of younger infants expressed a much greater degree of uncertainty about their MMR intentions: on the face of it, it would appear that as parents approach the time at which MMR is usually offered, they become more decisive.

While the passage of time itself may be important, it is unlikely to be the only factor influencing parents’ feelings about MMR.  It is clear from parents’ comments that feelings can run high and that many parents might accept the vaccine whilst still harbouring concerns.  

Despite all the research and information available, I still feel that it is a lottery to an extent as to whether it is a safe vaccination.  However, I do realise the risks if my child is not immunised and on balance decided to have him immunised and hope that he will not suffer as a result.  (Parent: Written comment)

With all the bad press MMR was getting at the time and constantly on the news, it was, in the end, quite a difficult decision to make and actually quite nerve wracking.  (Parent: Written comment)

I still have grave concerns regarding the MMR but I feel that I have no choice if I wish to protect my children from the illness.  Parents’ fears have not been dealt with, nor has the whole issue been dealt with in a reassuring way. (Parent: Written comment)

Uncertainty may be maintained for a considerable time, but the findings suggest that it can be diminished if there is an effective communication about MMR.  The following sections explore whether and in what ways exposure to MMR literature and support from health professionals appear to influence parents’ views and decisions about MMR.

3.4 The role of written resources

3.4.1 "MMR - Your Questions Answered"

Parents of older infants were more likely than the parents of younger children (62% vs 39%) to have seen the leaflet “MMR: Your Questions Answered”.  Two-thirds (67%) of those who had received an invitation for MMR had seen the leaflet.

Almost half (48%) of those who had seen the leaflet (and whose child was aged 12 months or more) felt that it gave “all” of the information they wanted, while a third (36%) regarded the information as only partial.  One in 10 felt that it had not provided the required information.  The remainder did not give an opinion or reported that they did not want or need any information (see Error! Reference source not found.).  Most respondents, however, reported that they regarded the leaflet as useful, with only one in 10 saying that it was “not useful” (Table 3‑ ). 

Table 3‑5 : Parents’ opinions about the MMR leaflet

MMR: Your Questions Answered		N=100%
Has seen the leaflet*	60%	1342
Leaflet provided “all” of the information wanted	48%	784
Leaflet was “very” or “quite” useful	86%	931
Leaflet was “not useful”	10%

* Based on parents of children aged 12 months+

We asked the Health Assistant for more information on the MMR vaccine.  She sent us two leaflets; MMR Your Questions Answered and a general information one on childhood immunisations.  She told us that there was more information available if we wanted.  We had pretty much decided to have our   son immunised; the leaflets reinforced our decision.  (Parent: Written comment)

3.4.2 The MMR Discussion Pack

The MMR Discussion Pack is intended to be resource for health professionals and to be source of additional information for those parents that want such support.  The Pack was familiar to very few parents.  Overall, only one in eight of all parents knew about the MMR Discussion Pack, and even fewer – one in 12 - had actually had an opportunity to read/look at the Pack.  Parents of older children (child aged ≥12months) were more likely (10% vs 5%) to have looked at the Pack or parts of it.  Parents who were dissatisfied with the amount of information in the leaflets were no more likely to have seen the Pack than other parents, suggesting that they had not been directed to it by health professionals.

However, of all those who had seen the Pack, almost three quarters felt that it gave either all (44%) or some (29%) of the information they wanted, and only one in eight parents felt that it did not give them the information they wanted at all.  One third described the Pack as “very useful”, one third as just “quite useful”, but a only a small proportion felt that it was not useful (7%) (see Table 3‑, below).

Table 3‑6: The MMR Discussion Pack

The MMR Discussion Pack		N=100%
Has read the Pack (child aged <12 months)	5%	783
Has read the Pack (child aged 12+ months)	10%	1332
Pack provided all or some of information wanted	72%	214
Pack was “very” or “quite” useful	62%	259
Pack was “not” useful	7%

3.5 The role of health professionals

Almost three-quarters of all parents had discussed MMR with a health professional. In most cases this was their health visitor, although a third had discussed MMR with their GP (see Table 3‑).  A small proportion had discussions with the practice nurse. Other health professionals who had been consulted included paediatricians, homeopaths, immunologists, midwives, psychiatrists, psychologists, pharmacists and school nurses.  Many of these were relatives, family friends or work colleagues.  The parents of older, MMR-eligible children (12 months or older) were more likely to have had an MMR-related discussion with a health professional than parents of younger infants (80% vs. 62%). 

Table 3‑7:  Discussions with health professionals

MMR discussion with:	Age of child		All
	< 12 months	12+ months
General practitioner	26%	36%	33%
Health visitor	51%	64%	59%
Practice nurse	10%	13%	12%
Other health professional	4%	9%	7%
Any health professional*	62%	80%	73%
100%=	793	1349	2142

* Parents may have had discussions with more than one health professional.

Parents of older (12 months +) children were more likely than parents of younger children to regard discussions with health professionals about MMR as effective: 44% of the parents of older children compared with only 28% of parents of younger infants said the discussions had provided “all of the information needed” (X²=52.7, df=1, p<0.0001).  

In fact, many parents (almost a third) reported having discussions with health professionals even though their decision had already been made.  In nine out of ten cases (88%), the already-made decision was to accept MMR.  The role of the health professional in those situations may not need to be particularly persuasive, but simply affirmative.  Of those who had not already made a decision when they had discussions, 53% said the discussion helped them to make a decision about MMR.  And, again, in 9 out of 10 cases, the decision was to accept MMR with only 6% deciding not to have MMR, and a further 6% who had yet to decide.  This would suggest that, for the most part, the discussions parents have with health professionals move them towards (and confirm) a decision to accept the vaccine (see Table 3‑ and Table 3‑5). 

When I discussed it with my doctor, I think my mind was pretty much made up and she simple said that she thought it was important in any case that the child was inoculated and we discussed it for three or four minutes.  I can't remember exactly what was said but it was an amicable discussion and I think she understood by that stage that my mind was relatively made up. (Parent: Interview)

Amongst those who had not felt that their discussions with health professionals had assisted the decision-making process, the discussion appeared to have left parents “undecided” rather than to have turned them away from MMR.

I have serious misgivings regarding our child's immunisation (MMR).  Whenever I have broached the subject with any Health Worker, they automatically go on the defensive.  Due to the adverse publicity recently, I feel that I could be putting my child's health at risk, I am aware that this is probably false and that the jab is safe but I am still uneasy about MMR.  (Parent: Written comment)

Table 3‑8:  Satisfaction with discussions with health professionals by age of child

MMR discussion with:	Age of child		All
	< 12 months	12+ months
Discussions gave “all” information needed	28%	44%	38%
Discussions helped to make decision	30%	39%	36%
Decision already made by time had discussion	27%	34%	31%
Max N (100%=)*	502	1072	1574

* based on all those who reported discussions with health professionals

Table 3‑9:  Discussion with health professionals and MMR behaviour/intention

MMR behaviour or intentions	Discussions with health professionals: impact on parents’ decision-making				All
	Helped make decision	Did not help make decision	Decision already made	Can’t say
Had MMR/ intend to	88%	38%	88%	47%	72%
Does not intend to have MMR	6%	6%	10%	5%	7%
Undecided	6%	55%	2%	49%	20%
N=100%	547	395	473	101	1516

The qualitative data (the written-in comments to the questionnaires and the focus groups) supported this: namely, that parents looked for support, to move them from almost crippling uncertainty and anxiety, to a decision.  Health professionals were contacted for information, but perhaps rather more for reassurance.

I came away reassured every time, I felt a bit more positive…. I found them very useful, they kind of reassured me that the allergic conditions were probably not linked to the MMR (my daughters) which I took on very seriously, her allergies and recurrent ear infections.  (Parent, Interview)

It's like looking for someone to say that MMR is 100 percent safe, which they won't say.  Someone to answer questions and hoping for support, which we got. (Parent: Written comment)

When you've just become a new mum and your emotions are so high and you just want to protect your children and do the best you can, you want to find out everything and get reassured.  They helped with that.  I'm not even questioning it this time, my daughter is going, she is just having everything that is available. (Parent: Written comment)

Trust in a health professional who knows you and your family plays a part:

Me and my husband searched on the Internet for information on the MMR vaccine as we felt that our GP was just giving us one side of the story.  We were told that there were no links and that we ought to have our child immunised, it all just seemed a bit one-sided.  After searching the Internet and reading the documents there, we found that what our GP had told us was true.  There is no definite link.  All the media hype had caused a lot of concerns over the vaccine (some of which we still have) but we trust our GP and believe that she wouldn't purposefully put our child in any sort of danger.  (Parent: Written comment)

The survey data suggest, however, that too many discussions may be counter-productive:  parents who discussed MMR with a range of different health professionals appear to be less likely to accept MMR than those seeing just one professional (See Figure 3‑3).  One explanation is that each successive health professional is seen as increasingly coercive, and it is this which sets the parent against vaccination.

I have discussed it with so many people, Health Professionals, other parents, friends and family, I also have all the leaflets and have personally researched it over the Internet.  What I find now is that no matter how much information and opinions I get, I am simply going round in circles.  I have no faith in the NHS over this issue and to them dictating to us mothers and limiting our choices (i.e., not supplying the individual vaccines), then again, neither do I trust the Private GP's who do provide the individual ones as they now seem to be cashing in on our plight.  In short, I absolutely cannot make a decision on this, meanwhile my daughter remains unprotected and exposed to these diseases, surely there must be a way to reassure parents either way, MMR or individual vaccines.  (Parent: Written comment)

It is also likely – as health professionals themselves suggested – that parents are simply seeking validation of their decision not to vaccinate and go from professional to professional hoping to get that affirmation.   

The Paediatrician thinks I should get it done saying she'll take full responsibility, but she can't, she makes me confused.  I got the impression the GP has not given his two children MMR but I may be wrong.  The Health Visitor didn't seen to know what she was talking about.  I'm stubborn and none of these people influences me, I've made my decision. (Parent: Interview)

I think most are looking to me to say it is ok to have single vaccinations. They get a bit frustrated when I will not do this. (GP: Interview)

Figure 3‑3:  Number of health professionals with whom parents discussed MMR with and MMR behaviour or intentions

These data suggest that one effective encounter may be crucial: if a parent has to be passed to a colleague, the opportunity to influence decisions may already have been lost.

3.6 The importance of the MMR contact

While contacts with health professionals are of undoubted importance in shaping parents’ decisions, it would appear that any NHS-led MMR intervention or contact, whether it entails seeing the MMR leaflet, or the MMR Discussion Pack, or having a discussion with a health professional, is what makes a difference.  This is particularly the case amongst parents of older infants and for those with no reservations or only “some” concerns.  Indeed, “MMR contacts” seem to exert only a small influence on the parents of younger children, but to be of greater significance to the decision-making of parents of the “older” MMR-eligible children. 

Looking only at those parents whose child was of an MMR-eligible age (12 months+: n=1349), we found that 86% had had at least one “MMR contact” (that is had seen the leaflet, or the Pack, or had had a discussion with a health professional), and that those who had such a contact were significantly more likely to have made a decision about MMR and, for the most part, to have decided in favour of accepting MMR than those who had had no such contact (X²=21.8, df=2, P<0.001).  The contact with the written or professional resource would appear to have the effect of decreasing uncertainty and increasing the likelihood of accepting MMR. 

Table 3‑10 shows the relation between MMR contacts and MMR behaviour/ intentions of parents by age of survey child.  A positive impact of the MMR contact on behaviour or intentions is largely confined to the parents of older (MMR eligible) children.   MMR contacts before 12 months do not appear to be particularly productive or useful.

Table 3‑10:  NHS-based MMR contacts and MMR intentions by age of child

i) MMR behaviour/ intentions: Survey infants aged less than 12 months	NHS-based MMR Contacts5
	No NHS MMR Contact	Any NHS MMR Contact
Has had MMR or intends to have MMR	52%	57%
Does not intend to have MMR	5%	7%
Undecided	43%	36%
N=100%	227	527

X² = 4.1, df=2, ns

⁵ Defined as access to at least one of the following: MMR leaflet, MMR Discussion Pack, discussion about MMR with a health professional

ii) MMR behaviour/ intentions: Survey infants aged 12 months or more	NHS-based MMR Contacts
	No NHS MMR Contact	Any NHS MMR Contact
Has had MMR or intends to have MMR	73%	80%
Does not intend to have MMR	2%	7%
Undecided	25%	13%
N=100%	176	1124

X² = 21.8, df=2, p<0.0001

Table 3‑11 shows the behavioural intentions of parents (for all ages) at different levels of concern for those who have had and those who have not had any NHS MMR contact[s].  Those who have had no access to the written materials (the leaflet and the Discussion Pack) and have not had discussions with any health professionals are less likely to have made a decision per se about MMR (X²=41.5, df=2, p<0.0001).  However, where there has been a MMR contact, it is associated with an increased likelihood of accepting (or planning to accept) MMR.  This is most pronounced amongst those with “some” concerns where the acceptance gain is in the order of 20%.  Indecision is most pronounced amongst parents with “serious” concerns who have had no NHS MMR contact.  The differences, however, are only significant for those with children aged 12 months or more.

Table 3‑11:  MMR concerns, contacts, and intentions

Opinions about MMR	MMR behaviour/ intentions	NHS MMR contacts
		No access to MMR resources	Any access to MMR resources
No concerns (a)	Has had/intends to have MMR	95%	98%
	Does not intend to have MMR	0%	<1%
	Undecided	5%	1%
100%=		76	369
Some concerns (b)	Has had/intends to have MMR	66%	86%
	Does not intend to have MMR	1%	<1%
	Undecided	33%	13%
100%=		215	800
Serious concerns (c )	Has had/intends to have MMR	22%	28%
	does not intend to have MMR	14%	25%
	Undecided	64%	47%
100%=		92	450

(a) X²=5.0, df=2, ns              (b) X²=48.7, df=2, p<0.0001        (c) X²=9.5, df=2, p<0.01

On their own, each of the NHS “resources” appear to play a small part in helping to shape parents’ decisions.  It is access to any of these which resources appears to increase the likelihood that a parent will make a decision, and for that decision to be to accept MMR proportion. 

… they really just helped with the fear, I mean I'm not medically knowledgeable, you know, the ins and outs about it, so it was really more just the fear of what could happen and what would happen. (Parent: Interview)

He gave more information, explained autism is on the rise because of new ways of diagnosing it.  He made me keener because he explained more. (Parent: Interview)

4. Professional practice in relation to MMR

4.1 Health professionals' opinions about MMR

The health professionals surveyed had varying degrees of involvement in the child immunisation programme. Table 4‑1 and Table 4‑2 below show what involvement, if any, that each health professional group had in immunisation issues as part of their work. 

Table 4‑1: Involvement in immunisation work by professional status

(Primary Care)

Immunisation work	Health Professional Category
	General Practitioner	Health Visitor	Practice Nurse/ Other primary care
Routine immunisation	70%	73%	80%
Talking with parents about immunisation	97%	98%	84%
Providing information to parents	87%	98%	86%
Giving advice to other health professionals	40%	47%	30%
No immunisation role	0%	0.4%	6%
N=100%	76	898	56

Table 4‑2: Involvement in immunisation work by professional status

(Public Health)

Immunisation work	Health Professional Category
	Public Health Practitioner	Imm Co-ordinator	Public Health Consultant	Comm Paediat
Routine immunisation	2%	(0%)	0%	(44%)
Talking with parents about immunisation	12%	(63%)	13%	(89%)
Providing information to parents	14%	(63%)	13%	(72%)
Giving advice to other health professionals	37%	(100%)	34%	(78%)
No immunisation role	53%	(0%)	55%	(6%)
N=100%	49	8	38	18

While almost all of the primary health care respondents had an immunisation role of some kind, about half of the public health respondents had no such involvement.  We have, therefore, excluded those with no immunisation role from some analyses. However, the fact that public health consultants may not have immunisation as part of their remit would not necessarily be known to the general public or, indeed, to other health professionals.  The lay public (eg. parents) and health professionals may therefore still feel that anyone working in public health is (or should be) an authority on immunisation issues.

Most of the health professionals who took part in the study were positive about routine immunisation and expressed generally low levels of concern about Diphtheria, Tetanus, Hib and Polio; slightly more - 5 to 6% expressed concerns about Pertussis and the MenC Vaccine (See Table 4‑3).

Table 4‑3:  Health professionals’ concerns about routine immunisations

	Primary Care (All)	Public Health
		Immunisation role	No immunisation role
Vaccine	% with concerns about each vaccine
Diphtheria	4%	3%	6%
Tetanus	4%	3%	11%
Polio	4%	6%	6%
Hib	4%	7%	6%
Whooping cough	7%	8%	9%
MenC	5%	10%	11%
MMR	50%	27%	39%
Total (N=100%)	1015	71	48

However, half of all the primary care and a quarter of all public health respondents expressed concerns about MMR.  Very few had “serious” concerns.  General Practitioners were less likely to have reservations about MMR than health visitors, but nevertheless a third (36%) still had “some” concerns about the vaccine.  A similar proportion of the Public Health Practitioners (PHPs) expressed concerns, although the other public health professionals were more positive about the vaccine (See Table 4‑4 and Table 4-5).  Public health professionals who had an immunisation role were more positive about MMR than those who did not (27% had concerns vs 39% of those with no immunisation role). 

Table 4‑4 : Opinions about MMR by professional status (Primary Care)

Concerns about MMR	Professional status			All Primary Care (100%=)
	General Practitioners	Health Visitors	Practice Nurses/ Other
No concerns	64%	49%	47%	50%	(499)
Some concerns	36%	48%	47%	48%	(472)
Serious concerns	-	2%	<1%	2%	(22)
N=100%	75	866	53		(994)

Table 4‑5 : Opinions about MMR by professional status

  (Public Health with immunisation role)

Concerns about MMR	Professional status			All Public Health with immun  role (100%=)
	Public Health Practitioners	Public Health Consultants*	Community Paediatricians
No concerns	61%	77%	(77%)	73%	(50)
Some concerns	39%	18%	(18%)	25%	(17)
Serious concerns	0%	6%	(6%)	2%	(2)
N=100%	23	25	17		(69)

* Including Immunisation Co-ordinators (N=8)

Table 4-5  shows only those public health professionals with an immunisation role.  A considerable number of health visitors expressed concerns about the MMR vaccine, echoing to a large extent, the views of parents.  None, however, had reported a personal experience in the course of their professional practice of a suspected link between MMR and autism or bowel disorder.

I feel it is wrong for the Government to state there is no risk and evidence is `conclusive' when there have been so many cases to dispute this.  USA research results are frightening and I do feel there must be a link with autism, although I never express my feelings to my clients… I admit to feeling uneasy about MMR (Health visitor: Written comment)

I would like to be able to say that it has been proved that there is no link between MMR and autism rather than there is no proven link.  (Health visitor: Written comment)

Although I am happy to offer children MMR I also have some doubts about its safety, so it is easy to empathise with parents needing to make decisions.  (Health visitor: Written comment)

Most believed that their personal views were not transmitted to parents. 

I am concerned about MMR only in certain cases.  Ninety nine point nine percent of the time I feel 100 percent certain that it is safe and very much to be recommended…Whatever fears or concerns I have, I wish to assure you that professionally I present the case for immunisation as per guidelines.  (Health visitor: Written comment)

I am beginning to feel concerned regarding the MMR but I do not pass this to my clients.  (Health Visitor: Written comment)

On balance, I believe MMR is safe and then I feel a bit wobbly again when some other `experts' appears to produce evidence against it.  I have read as much as I can about it and feel equipped to advise parents that the MMR appears to be safe.  (Health Visitor: Written comment )

Personally, I am not 100 percent convinced regarding `the MMR is safe theories'.  However, I do not see my personal views as pertinent when relaying information to my client group.  (Health visitor: Written comment)

However, as the parent data suggests, health professionals’ personal views may well affect their interactions with parents.  And, this is the perception of some parents too:

I don't think it is fair for the Health Professionals to be put on the spot when asked about a subject on which they do not have detailed knowledge.  My Health Visitor would only give text-book answers, but I could see she had reservations herself.  (Parent: Written comment)

Health visitors, the largest single professional group represented in the survey (comprising 87% of primary care professionals and 81% of all those surveyed), are the professionals to whom most parents are likely to turn to in the first instance for advice about MMR.  We show later that health professionals’ perceptions of their own practice are affected by their views and may, therefore, have a considerable influence on parental decisions about MMR.

4.2 MMR resources

4.2.1 "MMR - Your Questions Answered"

The leaflet "MMR: Your Questions Answered" was not routinely distributed by GP practices to all parents: a third of the primary care respondents indicated that, within their practice, the leaflet was provided only if the parents needed or wanted more information. Health visitors were more likely than GPs to give the leaflets as a matter of routine to parents (70% vs. 37%). 

Although many did feel that the leaflet provided parents with all the information they needed, a sizeable proportion (43%) felt that the leaflet’s content only partially met parents’ information needs.  However, while fewer than half (45%) rated the leaflet as “very useful”, less than 1% regarded it as not useful at all (Table 4‑6).  Primary care health professionals with concerns about MMR were less likely to rate the leaflet as very useful, either for professionals or parents.  Elaboration of the leaflet was regarded as desirable by only a relatively small proportion of respondents and, indeed, few felt that it needed to be greatly revised (see Table 4-7).  Above all, it was felt that the most pressing need was to ensure that the leaflet was made routinely available to parents.

Table 4‑6: Health professionals’ perceptions of MMR leaflet

MMR LEAFLET: “Your Questions Answered”	Primary care			Public Health*
	General Pract	Health Visitor	Practice Nurse/Other	Public Health Pract	Public Health Cons/IC	Comm Paediat/ Other
Seen/aware of  the leaflet	na	na	na	87%	80%	95%
Leaflet is routinely provided to parents by practice	37%	70%	72%	na	na	na
Leaflet gives “all information” parents want	54%	58%	52%	45%	47%	55%
Leaflet is “very useful”	25%	47%	38%	30%	25%	30%
N=100%	76	898	56	23	25	21

* Only includes to public health professionals with an immunisation role

Table 4‑7:  Views about ways in which MMR leaflet might be improved

MMR LEAFLET: “Your Questions Answered”	Primary care				Public Health*
	General Pract	Health Visitor		Practice Nurse/Oth	Public Health Pract	Public Health Cons/IC	Comm Paediat/ Oth
Leaflet could be improved if:
Used simpler language	13%	13%	14%		13%	12%	33%
More technical details	9%	23%	9%		0%	4%	5%
Was routinely available	26%	22%	38%		na	na	na
Had more information	8%	19%	14%		26%	24%	14%
Was shorter	1%	1%	0		9%	8%	5%
Other change	8%	7%	4%		16%	9%	29%
Max N=100%	76	898	56		23	25	21

* Only includes public health professionals with an immunisation role

4.2.2 The MMR Discussion Pack

Almost all of the frontline professional respondents were aware of the MMR Discussion Pack: most (92%) reported that it was “very easy” to access a copy, and 98% reported that they had read all or part of the Pack.  Health visitors were more likely than GPs or practice nurses to have read it in its entirety (70% vs. 32%).  

The Pack was used, for the most part, as an information resource for the professionals themselves.  This was particularly the case for health visitors:

Yes, it's just to refresh my memory and also I photocopy bits out of it to give to parents on specific things, although I find the leaflet is has really got most of the information that they ask for. (Health visitor: Focus group)

We only got 2 copies in our practice. I've used it to inform my own practice, and also just for discussion with parents. If there's been a particular issue, like, going back to the egg allergy last week, there is a section on that, so I went back and I read that again, so I was clear in my mind, and I've given the parent the opportunity to see that information again. And to see if that will help them to make a decision. (Health visitor: Focus group)

Table 4‑8: How primary care health professionals use the MMR Discussion Pack

Use of Pack	Professional status
	General Practitioners	Health Visitors	Practice Nurses/Other	All
Has read Pack (all or part)	92%	99%	52%	98%
Uses in discussion with parents	33%	62%	48%	59%
Uses as an information resource for self	47%	75%	65%	72%
Gives to parents	29%	59%	35%	55%
N=100%	76	898	54	1030

Whereas two-thirds of the primary care health professionals regarded the Pack as “very useful” to professionals, only a third felt that it would be as useful for parents.

Table 4‑9: Ways in which the pack might be improved: perceptions of own and parents' needs (Primary Care)

How pack might be made more useful	For health professionals	For parents
Used simpler language	3%	15%
Had more technical details	13%	7%
Was available in a summary format	48%	48%
Contained more information	7%	5%
Was shorter	2%	2%
Was in different format	2%	2%
Was routinely available for parents	22%	25%
Other change	6%	6%
Max N=100%	1030

Primary Care health professionals’ views about the value of the Pack were closely associated with their opinions about MMR (see Table 4‑10).  Those with concerns about MMR were more likely to have more negative perceptions of the Pack and, in particular to feel that the Pack did not give them all the information they needed.  They also regard the Pack as only “quite” or even “not” useful  – either for their own needs or for parents’ needs.

Table 4‑10 Opinions about MMR and perceptions of the MMR Discussion Pack (Primary Care)