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