healthscotland.com

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

Contents:	Summary 1. Introduction 2. Research design and methods 3. Parents' opinions, decisions and behaviour 4. Professional practice in relation to MMR 5. Implications for HEBS communication strategy Appendix A: Parent survey data Appendix B: Primary Health Care Professionals Survey Data Appendix C: Public Health Care Professionals Survey Data

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)

Perceptions of MMR Discussion Pack	Concerns about MMR
	No concerns	Some/serious concerns	All
Gives “all the information I need”	79%	58%	69%
“Very useful” to health professionals	73%	58%	66%
“Very useful” for parents	45%	34%	39%
Max N=100%	490	489	979

Health visitors are the professional group working most closely and routinely with parents and are, often, the person with whom discussions about MMR take place.  It was clear that health visitors use the Pack in a range of different ways.  The following reflects the practice of many who participated in the focus groups:

Well what I tend to do is …it varies very much on the parents, some parents are quite happy you know usually second or third time if you've had it first time.  If there are concerns then I will go out with the pack, I'll do a home visit with the pack at that time and take what are their concerns rather than just introduce the pack and give them concerns that maybe they didn't have, so I will ask them what area about the MMR they're concerned about and we'll look through the pack together and then if they've got anything that they want I'll sort of focus that bits when I get back and post that back to them so it reinforces but I don't sort of go through the pack with them willy nilly, I actually ask them what they're concerns are on the grounds that I don't really want to give you more concerns than you already have. (Health visitor: Focus group)

The Pack was seen as useful on its own, but was felt to be particularly influential when used as the basis for, and to support, discussions with parents:

I think they've quite impressed when you go in with your folder cause like you have got a folder all about MMR and you're taking them seriously if they have doubts.  Again, I've got a high uptake of MMR. (Health visitor: Focus group)

I think at the end of the day the pack's really good but unless you go with it, you know if you sent it through the post to them they probably wouldn't read it and do whatever they're doing and you send them the leaflet which is all virtually the same thing, but the fact is you know they take credence in the fact that you're there saying oh aye it's fine .... (Health visitor: Focus group)

Some stressed the need to present information at the appropriate level for individual parents.  There were some concerns that the detail in the Pack may be inappropriately or too complex for some people:

I mean if you sent it to them they'd read it all, it's too much and what you're trying to do is sort out with them what the specific concerns are and then do that which would mean that you would need to be there with them.  Also as I say you have to bring it down or up to their level or whatever, which you need to be there to do. (Health visitor: Focus group)

One health visitor was enthusiastic about the value of the Discussion Pack.  Her experience would appear to echo the findings from the parent element of the study about the influential part that an MMR contact can play in helping parents make a decision:

I have found the Discussion Pack particularly helpful, in fact out of five copies, I have lent it to, all five have elected to have their child immunised with MMR.  I lent the Pack each time following a home visit, each couple claimed to be undecided before the visit.  Those couples in the practice who have decided not to have their children immunised have not taken up the offer of the loan of the Pack." (Health visitor: written comment)

4.3 Interactions with parents

The ways in which health professionals’ approach MMR may influence immunisation outcomes.  Primary care health professionals were asked to assess their MMR-related practice with parents in terms of:

• the extent to which they feel able to answer parents’ questions
• how confident they feel when discussion MMR with parents
• whether they believe their discussions with parents about MMR help them to make a decision

While 7 in 10 reported that they could answer “all or most” of parents’ questions about MMR, only a quarter (28%) actually appear to be wholly confident when discussing MMR.  Nevertheless, most feel that their discussions with parents do help them to make a decision.  Health visitors were, in general, more positive about their MMR-related practice than GPs or practice nurses (Table 4‑11).

Table 4‑11:   Perceptions of own professional practice

MMR-related practice	Professional status			All
	General Practitioners	Health Visitors	Practice Nurses/other
Can answer parents’ questions “all or most of time”	63%	73%	52%	72%
“Very confident” when discussing MMR	22%	30%	11%	28%
Discussions with parents “help them to make decision”	71%	76%	44%	74%
N=100%	76	898	56	1030

The relationships between these variables were statistically significant.  Primary care health professionals who felt confident in their interactions with parents about MMR were more likely to feel both that they could answer parents’ questions and help them to make a decision about MMR (see Table 4‑12).  However, the factor which most strongly influenced health professionals’ perceptions of their own practice was their personal opinions about MMR: those who had concerns about the vaccine were significantly less likely to feel confident and influential in their interactions with parents (see Table 4‑13).

The survey data alone cannot tell us the direction and exact nature of these relationships, although it would appear that a belief in the safety and value of MMR is a critical factor in determining how health professionals respond to parents.  What influences those beliefs in the first place, however, does not appear to be a function simply of exposure to the various resources about MMR - such as the Discussion Pack  - that are available for the professionals.  Nevertheless, primary care health professionals identified better information sources as a key support need and this was particularly the case amongst those with MMR concerns.

Table 4‑12: Confidence when discussing MMR with parents and perceived impact on practice (Primary Care)

MMR-related practice	Perceptions of own confidence
	Very confident	Quite confident	Not confident
Can answer parents’ questions “all or most of time” (a)	96%	65%	13%
Discussions with parents “help them to make decision” (b)	88%	72%	36%
Max N=100%	288	696	32

(a) X² = 151.2, df=2, p<0.0001 (all/most vs other)
(b) X² = 59.8,   df=4, p<0.0001 (help vs other)

Table 4‑13: MMR-related practice (Primary Care) by opinions about the vaccine

MMR-related practice	Concerns about MMR
	No concerns	Some/serious concerns
Can answer parents’ questions “all or most of time” (a)	83%	61%
“Very confident” when discussing MMR (b)	41%	15%
Discussions with parents “help them to make decision” (c )	79%	72%
Max N=100%	490	489

(a) X² = 59.3, df=1, p<0.0001           (no concerns vs any concerns)
(b) X² = 85.1, df=1, p<0.0001           (no concerns vs any concerns)
(c) X² = 6.7,   df=2, p<0.05                (no concerns vs any concerns)

Everyone must give out the same message and literature and be aware of and disseminate the latest research findings/medical comments etc.  It is only by professionals being confident in the message that parents will have confidence in the process.  (Health visitor: Written comment)

4.4 Interactions with other health professionals

All of the different health professional groups, to a greater or lesser extent, gave advice to other health professionals about MMR.  Three-quarters of the primary care professionals reported that they had sought advice about MMR from a range of other health professionals (see Table 4‑14).

Table 4‑14: Who primary care professionals have consulted about MMR

Had discussions about MMR with:
Immunisation Co-ordinator	21%
Director of Public Health	19%
Public Health Practitioner	10%
Primary Care Colleagues	51%
Other colleagues	7%
Total (N=100%)	(1045)

The advice received from the local Immunisation Co-ordinator or Director of Public Health was more often rated as “very useful” than that received from others.

In the same way that primary care health professionals’ perceptions of their effectiveness with parents was influenced by their own personal views, public health professionals who had concerns about MMR were also less likely to feel that the discussions they had with frontline professionals had been helpful.  

4.5 Perceptions of professional roles

A series of questions was posed, intended to gauge health professionals’ perceptions of their professional role in relation to child immunisation.  The Primary Care respondents were asked to indicate, for two consecutive series of items, their level of agreement with six statements: first in relation to perceptions of their “current” and, second, in relation to perceptions of their “ideal” immunisation roles.  The responses were then scored to give a distribution representing a continuum from roles we defined, at one end of the scale, as “advocacy” and at the other end as “advisory”⁶.  On the basis of individual scores, immunisation "advocates" were defined as those who more often indicated through their responses that they regarded their role as one which involved the positive promotion of immunisation, while "advisors" were defined as those who perceived their role to be one which entailed the provision of impartial information with an emphasis on helping parents make a decision - be it to immunise or not. 

The "advocacy" role was seen to be the ideal for fewer than a third and most felt they had (and should have) a support or advisory role instead.  More than three-quarters (78%) conceptualised their current immunisation roles as broadly similar to their ideal role. 

Table 4‑15: Perceptions of current immunisation role

Perceptions of own current immunisation role	Professional status			All primary care
	General practitioner	Health Visitor	Practice Nurse/Other
Advocate*	49%	29%	47%	31%
Neither advocates or advisors**	12%	12%	13%	12%
Advisory	40%	60%	40%	57%
Total (N=100%)	76	850	53	979

*Advocate: mean score = -0.1 to -2.0
** Neither advocates or advisors: mean score = 0.00
***Advisory: mean score = 0.1 to +2.0

Table 4‑16 : Perceptions of ideal immunisation role

Perceptions of own ideal immunisation role	Professional status			All primary care
	General practitioner	Health Visitor	Practice Nurse/Other
Advocate*	33%	25%	41%	27%
Neither advocates or advisors**	8%	13%	10%	12%
Advisory	59%	62%	49%	61%
Total (N=100%)	73	821	51	945

*Advocate: mean score = -0.1 to -2.0
**Neither advocates or advisors: mean score = 0.00
***Advisory: mean score = 0.1 to +2.0

Health Visitors were more likely than General practitioners to define their immunisation role - both in its current and ideal forms - as advisory rather than advocacy (60% vs. 40%: p<0.01). 

Many health visitors, in their written-in comments and in the course of the focus group discussions, reiterated this view: that their role is to provide information to allow parents to make their own decisions. 

The role of the Health Visitor in my opinion is to make sure the parent has enough information to make informed choice.  (Health Visitor: Written comment)

The role of the Health Professional is to enable the parent to give informed consent but not to coerce the patient into a decision that they are unhappy with. (Health Visitor: Written comment )

I feel that the parents have to be happy with the decision and at the end of the day, Health Professionals can only advise.  (Health Visitor: Written comment)

I aim to give correct information so parents can make an informed decision whether they decided to immunise or not. (Health Visitor: Written-in comment)

However, some observed that information did not necessarily make the difference and that too much information – perhaps like too many discussions - may be counterproductive:

I can give all the latest research findings confirming the benefits of immunisations to parents and all the facts available, yet it would still not be enough.  (Health Visitor: Written comment)

Most people (including Health Professionals) do not read leaflets given to them by other people.  Simple information does not generally answer the questions people ask, complex information gives the answers but feels too complicated to those on the receiving end!  (Health Visitor: Written comment)

… parents make decisions based on a variety of factors rather than just `information'.  (Health Visitor: Written comment)

Many parents feel that they are being pressurised into agreeing MMR for their children and so are digging their heels in.  Bombarding them with more information would exacerbate the problem. (Health Visitor: Written comment)

Immunisation “advocates”, however, more often perceived their practice to be confident, informed and effective.

⁶ Each item was scored on a scale from -2 to +2. A mean score for each respondent was calculated in which negative scores (-0.1 to -2.0) indicating an "advocacy" role and positive scores (+0.1 to + 2.00)  indicating a "support role". Those with a mean score of 0 were defined as “neutral”.  These items and the scoring system have not been validated and are intended simply to provide a picture of professionals’ perceptions of their roles in relation to immunisation.

4.6 Information and support needs

Table 4‑17 shows the range of perceived support needs amongst the health professional respondents.  In general, those with concerns about MMR more often wanted better information resources, to have access to research findings, expert advice and, perhaps more than anything, more information about autism itself.

It was felt that the Boards and Trusts had failed to keep up with the media onslaught and that a range of methods need to be employed to ensure that health professionals are adequately informed about MMR:

It seemed to take forever for the Trusts etc, to bring in their Public Health staff to counter the claims in the press, it gave the impression that they weren't sufficiently sure of their facts to come on TV, or be quoted in the press to counter these claims.  This left the frontline staff very unsupported.  I think we lost the battle at this point!  (Health Visitor: Written comment)

There has been a significant gap in keeping staff currently up-to-date with most recent information and this should be looked at e.g., road shows/training updates.  (Health visitor: Written comment)

I think it would be helpful if regular (e.g., monthly) training/update sessions were arranged for Health Visitors/Practice Nurses/Paediatric staff/GP's to increase confidence and enthusiasm for immunisation generally.  (Health visitor: Written comment)

Table 4‑17: Concerns about MMR and support needs

Support needs	Concerns about MMR
	No concerns	Some/serious concerns	All
Better information resources	24%	31%	27%
Access to research findings	40%	47%	44%
Access to expert advice	23%	41%	32%
Better materials for parents	40%	47%	43%
More information about autism	61%	68%	65%
More information about Crohn’s	53%	59%	56%
Max N=100%	502	500	1002

As we have already elaborated, the MMR Discussion Pack is valued and positively rated and has, undoubtedly, started to address to health professionals’ needs.  Nevertheless, there was a view that it would be even more useful if regular updates were available and if it were available in summary format. 

It was clear that health professionals’ perceptions of their information and support needs extended beyond the list provided in the questionnaire to include: more research; a greater sense of trust in government and health professionals around this issue; and a move away from rewarding immunisation targets, and access to single vaccines.  These were all factors which, it was felt, affected their practice.

Many health professionals believed there was a need for further research into the purported links between MMR and autism/Crohn’s and, over and above that, research and information to address the knowledge deficit in relation to autism that has been highlighted by the MMR debate.

There were real concerns in relation to the problems created by the lack of trust on the part of parents in relation to information that is perceived to emanate from Government sources, which they (parents) regard as biased and not necessarily truthful.  As the data from parents showed, this mistrust extended to some health professionals who are seen as agents of government and “toeing the party line”.  Addressing these perceptions would help health professionals to promote MMR.

Parents ask for non-Governmental, non-NHS information as they have a `conspiracy theory' view that the Government has a vested interest in or is influenced by drug companies to get vaccinations done.  (Health visitor: Written comment)

Many parents appear to distrust/disbelieve information from `the Government'.  This needs to be tackled.  (Health visitor: Written comment)   

I have noticed a change in my relationship with clients around MMR issues, they suspect another agenda and do not trust me because I represent the Government and the `Government' is trying to save money and doesn't care about individual choice.  How can we re-establish trust?  (Health visitor: Written comment) 

The issue of GP targets was raised by GPs, health visitors and parents as a factor, which may also have contributed to a climate of suspicion and distrust of health professionals:

I feel that the need to reach practice immunisation targets makes some parents distrust the advice they receive from their GP.    (GP: Written Comment)   

Some argued that targets should be abandoned to help restore parents’ trust in health professionals, and to ensure that health professionals are not influenced by the desire simply to reach the targets:

It is important to me that the children in my area are fully immunised therefore, I favour high uptake but not for the financial gain of the practice.  I wish for practice immunisation targets to be achieved for the health of the nation without linkage to financial gain.   (Health visitor: Written comment)

Take the financial incentive away from GP targets.  Parents often comment on how GP's only insist on MMR because they get paid for it.  I feel this may be part of the reason parents don't believe a lot of the factual information given to them.  (Health visitor: Written comment)

Lack of access to single vaccines was repeatedly raised by health professionals, (as it was by parents), as a factor affecting uptake.  There was a view expressed by some, that parents that are not being offered a real choice - again, echoing parents’ views.  Some speculated that uptake of single vaccines, if available, may not actually be that high.  Nevertheless, there was a view that the absence of “choice” affected their discussions with parents, and some believe that it is better to have children being vaccinated singly rather than not at all. 

While I believe that the MMR is safe, if we are truly to work in partnership with parents, giving choices, perhaps single vaccines should be considered in some cases.  (Health visitor: Written comment)

I believe that if separate vaccines were available, there would not actually be a huge surge in their uptake but it would provide parents with the security of choice and alleviate many anxieties.  (Health visitor: Written comment)         

From speaking to many parents, I feel that they would like the choice of single vaccines.  Even if this were available, I think that the vast majority would have the MMR.  People don't like to have choices taken from them and this is the main problem we face.  (Health visitor: Written comment)

This was not a view shared by most GPs: 

I believe the department is right in sticking to their guns with offering MMR vaccine and not individual vaccines.  (GP: Written comment)