Publication
Evaluation of the MMR discussion pack and preparation of the MMR communication strategy
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 |
1998 |
| 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+ |
|
|
| 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 PackThe 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: |
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: |
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 |
Has had/intends to have MMR |
95% |
98% |
| Does not intend to have MMR |
0% |
<1% |
|
| Undecided |
5% |
1% |
|
| 100%= |
76 |
369 |
|
| Some concerns |
Has had/intends to have MMR |
66% |
86% |
| Does not intend to have MMR |
1% |
<1% |
|
| Undecided |
33% |
13% |
|
| 100%= |
215 |
800 |
|
| Serious concerns |
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)