Parents are often uncertain about the risks and benefits of immunisation. Effective delivery of information can help encourage uptake in children and young people
Sarah A Redsell, PhD, CPsychol, BSc, RGN, RHV, is principal research fellow, School of Nursing, Midwifery and Physiotherapy, University of Nottingham; Helen Bedford, FRCPCH, PhD, MSc, MFPH, RGN, RHV, is senior lecturer in children’s health, UCL Institute of Child Health, London; A Niroshan Siriwardena, MBBS, MMedSci, FRCGP, PhD, is foundation professor in primary care, School of Health and Social Care, University of Lincoln; Jacqueline Collier, PhD, CPsychol, MSc, BSc, RGN, was at the time of writing professor of health services research, School of Nursing, Midwifery and Physiotherapy, University of Nottingham; Philippa Atkinson, BSc, RN (Child), RGN, RHV, is health visitor, Nottingham City PCT.
Redsell SA et al (2010) Exploring communication strategies to use with parents on childhood immunisation. Nursing Times; 106: 19, early online publication.
While childhood immunisations are voluntary in the UK, healthcare professionals strongly encourage uptake, which is also endorsed by the Department of Health. A few parents refuse immunisation outright but many more are uncertain about the risks and benefits.
Parental uncertainty about immunisations was exacerbated during the controversy over the mumps, measles and rubella vaccine. This prompted many studies exploring parents’ views about immunisation delivery, which reported considerable criticism of the approach of healthcare professionals to this issue.
The National Institute for Health and Clinical Excellence (2009) recently published guidance on reducing differences in immunisation uptake. Six key areas were identified for improvement: immunisation programmes; information systems; training; the contribution of nurseries, schools and colleges; targeting groups at risk of not being fully immunised; and hepatitis B immunisation for babies.
This article examines the literature on healthcare professionals’ views about the universal childhood immunisation programme and information provision for parents. It also highlights relevant issues in relation to improving access and information delivery.
Keywords Immunisation, Vaccination, Information delivery
- This article has been double-blind peer reviewed
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- Primary care trusts seeking to improve access to immunisation services need to ensure frontline staff to undertaking targeted home visiting have the necessary knowledge and skills to communicate with parents.
- Healthcare professionals carrying out immunisation consultations with parents need to continue to improve their understanding of the evidence base behind recommended vaccinations.
- They also need to reflect on how they deliver immunisation information in their practice. Is it done in a paternalistic way or does it support parental decision making? The key is engaging with parents about immunisation related decisions and providing appropriate support.
Childhood immunisation uptake is generally high in the UK. The majority (92%) of babies have received a primary course of the “five in one” DTaP/IPV/Hib vaccine by 12 months (The NHS Information Centre for Health and Social Care, 2008). This protects against five different diseases: diphtheria – D; tetanus – T; pertussis – P; polio (IPV – inactivated polio vaccine) and Hib (Haemophilus influenzae type b). However, rates in some primary care trusts (PCTs) are low, with variation within districts reflecting inequalities in uptake (Cummins et al, 2004).
While childhood immunisations are voluntary in the UK, healthcare professionals strongly encourage parents to accept them on behalf of their children, which is endorsed by the Department of Health. Children with incomplete immunisation records include those who have started but not completed the course (under vaccinated children) and those who have had no vaccines at all (unvaccinated children).
Under vaccination is often attributed to service level factors such as poor access to immunisation clinics (Kendrick et al, 2000). Low uptake (unvaccinated children) is often the result of parents being inadequately informed of the need for immunisation or when they have misconceptions about its safety and effectiveness (Samad et al, 2006). Some children remain unvaccinated because of poor parental knowledge.
The public controversy over the mumps, measles and rubella (MMR) vaccine in the 1990s highlighted apparent difficulties in relation to the delivery of immunisation information. Although parents consider healthcare professionals to have a valuable role in informing them about immunisation, the extent of their influence depends on trust (Smith et al, 2007) and during the MMR controversy this trust was challenged.
This article examines access to immunisation services, and healthcare professionals’ views about the universal childhood immunisation programme (World Health Organization, 2008). It also discusses how information should be provided to parents in light of the relevant recommendations in the National Institute for Health and Clinical Excellence (2009) guidance. The discussion focuses mainly on the immunisation programme for children up to the age of three, as this is the area in which there has been the most controversy (Table 1).
Improving access to immunisation services
NICE (2009) guidance suggested that some groups have poor access to immunisation services and children remain under vaccinated. It recommended ways in which access to these services could be improved, which include:
- Extending clinic times;
- Ensuring clinics are child and family-friendly;
- Extending the availability of appointments for immunisation;
- Offering home visits, where appropriate.
The limited research on home visits suggests that other factors need to be considered when introducing or evaluating the effectiveness of this service. An international systematic review evaluating the effectiveness of home visiting programmes on the uptake of childhood immunisations identified several papers detailing various home visiting programmes by health visitors, community mothers (that is, non professionals) , public health nurses and other professionals (Kendrick et al, 2000). The combined results found these programmes had no effect on the uptake of immunisation. However, the programmes are likely to have been conducted in the wake of the MMR controversy when concern about vaccination was high and parental confidence in healthcare professional intervention may have been low. Furthermore, offering targeted home visiting conflicts with some healthcare professionals’ beliefs and therefore may not always be delivered with conviction.
A recent UK qualitative study among 22 health visitors explored their perceptions of their role regarding immunisation (Redsell et al, 2010). The results revealed that while some administered vaccines to children on their caseloads and supported the view that they were helping families to access services by immunising at home, others felt parents failed to attend immunisation appointments because of other priorities. In this case, immunising at home took the responsibility of attendance away from parents, thereby giving them permission to miss appointments.
A few health visitors felt that if families did not attend repeated immunisation appointments, this indicated they did not want their child to have them, a view which should be respected. Some parents who are uncertain about immunisation do not accept the risks posed by either accepting or explicitly refusing; rather they decide to opt for a kind of indeterminate state where they are neither fully committed to vaccination nor non vaccination.
Serpell and Green (2006) suggested that in making this compromise parents aim to reduce the risks of either decision. However, the authors pointed out that in reality these parents are making a decision not to have immunisations by omission. Non attendance for appointments may be a way that these parents covertly refuse immunisation, without entering into the debate. Home visiting to discuss the issue may be effective for such parents who feel more comfortable on home territory.
Improving healthcare professionals’ knowledge and skills
A paper by Andrew Wakefield and colleagues, published in 1998 and interpreted as suggesting a causative link between the MMR vaccine and autism, sparked concern over vaccine safety and escalated into a major public controversy. Uptake of the vaccine fell to a record low, demonstrating the negative impact media reporting can have on parental decision making. Parents of unvaccinated children (Sporton and Francis, 2001) and vaccinated children expressed concerns about vaccine safety (Salmon et al, 2005; Raithatha et al, 2003; Evans et al, 2001). They criticised the information they received about the vaccination from healthcare professionals, suggesting this was of poor quality and biased in favour of immunisation (Smailbegovic et al, 2003; Evans et al, 2001, Sporton and Francis, 2001).
In a more recent investigation, health visitors thought the MMR situation was recovering (Redsell et al, 2010). Smith et al (2007) also reported an increase in the proportion of parents who considered MMR to be completely safe or to carry only a slight risk. However, the current MMR immunisation rate of 85% remains lower than the peak coverage of 92% achieved in 1995-1996 (The NHS Information Centre for Health and Social Care, 2008; 2005).
Much of the research on healthcare professionals’ knowledge and skills around immunisation information delivery emerged in the years after the MMR crisis. Petrovic et al (2001) conducted a survey on the second dose of the MMR vaccine among healthcare staff (health visitors n=148, practice nurses n=239 and GPs n=206) working in North Wales. The results showed that 48% (220/460) had reservations and 3% (15/460) disagreed with the policy of giving the 2nd dose. Although health visitors were nominated as the best source of advice on the vaccine, only 61% of this group reported feeling very confident about explaining the two dose schedule to a parent. The authors concluded that healthcare professionals’ knowledge and practice about MMR vaccine varies considerably.
Henderson et al (2004) undertook a survey to ascertain the views of GPs working in Scotland about immunisation. The survey had a good response rate (73%), of whom 28% had concerns about the MMR vaccination. A Department of Health (2004) survey reported that at that time 20% of GPs, 12% of health visitors and 11% of practice nurses were concerned about some aspect of the immunisation programme. The main concerns were related to MMR, including high levels of parental anxiety, the introduction of the new five in one vaccine and parents’ lack of choice. Although nine out of 10 of those interviewed claimed they were confident about explaining immunisation issues to parents, inconsistencies in knowledge were apparent both within and between all groups of healthcare professionals (DH, 2004).
Clearly the findings of these papers need to be set in the context of the MMR crisis, which is now subsiding. However, they highlight how poor healthcare professional understanding of the evidence base on immunisations can make them susceptible to public crises of confidence (Hilton et al, 2009).
Such misunderstandings are neither unique to the UK nor to MMR. A survey among 150 practice nurses in New Zealand in 2004 found that 20% believed six week old babies were too young to be immunised because of misconceptions about the infant immune system (Petousis-Harris et al, 2005). This study also reported that additional support training was needed to improve knowledge about vaccination and side effects, together with specific strategies to deal with controversial information obtained by parents from the internet.
NICE (2009) recommended that all staff involved in immunisation services are appropriately trained and regularly updated. Training should be tailored to individual needs to ensure staff have the necessary skills and knowledge, for example, communication skills and the ability to answer questions about different vaccinations (NICE, 2009). In the UK, increasing access to training for all healthcare professionals and support staff involved in immunisation using the national minimum standards for immunisation training (Health Protection Agency et al, 2005) should help improve practitioners’ knowledge.
NICE (2009) acknowledged the need to ensure healthcare professionals’ knowledge is up to date. It also underlined the importance of access to resources such as the “Green Book” (DH, 2010) and training to ensure staff have the necessary skills and knowledge to answer parental questions.
Providing tailored information, advice and support
NICE (2009) recommended that parents and young people should be provided with tailored information, advice and support to ensure they know about the recommended routine childhood vaccinations and the benefits and risks. The Healthy Child Programme (DH, 2009) also suggested that “parents or carers should be provided with good quality, evidence-based information and advice on immunisations including the benefits and possible adverse reactions”.
McMurray et al (2004) conducted 69 interviews with parents and 12 with primary care practitioners, managers and immunisation coordinators to explore decision making and education needs in relation to the MMR controversy. Parents and practitioners identified a need for new approaches to support decisions. The authors suggested that immunisation information might be better received if provision of support is integrated into parents’ pre-existing experiences and understanding.
A longitudinal survey in Australia (n=195) revealed that some mothers want healthcare professionals to provide them with balanced information on the risks and benefits of immunisation as well as the risks and consequences of the disease to support their decision making (Wroe et al, 2004).
A systematic review exploring the support needs of parents making decisions about their child’s health identified three overarching themes (Jackson et al, 2008). These were needs for:
- Timely, consistent, up to date, evidence based information tailored to the individual, delivered in a variety of formats from trustworthy sources;
- The opportunity to talk with others in the same situation to share information, experiences and ideas;
- The ability to be in control of one’s level of preferred involvement in the decision making process (Jackson et al, 2008).
There is little evidence base to date examining whether healthcare professionals in the UK provide balanced information for parents to help them with immunisation related decisions. In Redsell et al’s (2010) study, health visitors reported that they worked in partnership with parents; however, they went on to describe how they provided parents with information about immunisation and then withdrew from the decision making process altogether. This way of communicating has been described as an “information giving model” where information is shared (from professional to patient) but the informed patient is left to make their own decision and the healthcare professional has no further input in the process (Charles et al, 1997). This model of information provision appears to be commonplace among nursing professionals (Redsell and Buck, 2009).
The NICE (2009) guidance is welcome because it highlights areas of practice in relation to immunisation that need to improve, underpinned by research evidence. This article has focused on two main areas: namely, problems with access that might lead to under vaccination and problems with poor understanding of the risks and benefits of immunisation that might lead to non vaccination.
PCTs considering expanding services to include home visiting need to have a greater understanding about why parents do not bring their children to immunisation appointments. They may be covertly refusing and there may be issues around home visiting with the intention of vaccinating their child. Furthermore, health visitors hold a wide variety of views about home visiting (Redsell et al, 2010) so PCTs might also wish to identify an appropriate person to take on this role.
Clearly some healthcare professionals deliver immunisation information to parents using a knowledge deficit approach. This assumes that parents who are uncertain or refuse immunisation lack knowledge and the healthcare professional’s role is simply to communicate information. However, Serpell and Green (2006) stated that providing parents with all the facts about complex health issues and assuming they will take the optimal decision by default is not effective.This approach is also considered outdated in most other areas of healthcare (DH, 2003).
There is a public health argument that providing balanced information about the risks and benefits of immunisation might reduce uptake as those who misunderstand risk may subsequently refuse vaccination for their child. However, inother areas of healthcare, informed choice and shared decision making are being incorporated (DH, 2003) and immunisation cannot be the exception.
The shared decision making model (Charles et al, 1997) supports the view that patients - or parents in this case - should have an active role in health related decisions. Clearly, true “shared decision making” is difficult to achieve during immunisation consultations, because of the overriding public health need for immunisation levels to be high enough to achieve herd immunity. However, healthcare professionals could provide additional support to parents with their decision making. Staff may need further guidance to help them understand and value parents’ views and may also require extra skills to facilitate partnership with parents in the decision making process.
Parents need guidance on how to assess the validity of information from different sources. One way healthcare professionals could suggest they do this is to access a recommended website, such as www.healthtalkonline.org. In terms of delivering immunisation information, healthcare professionals need to listen to parents’ concerns and questions, openly discuss both the risks and benefits of immunisation and reach a consensus on how to proceed. This may involve either party gaining more information before decision making and acknowledging that further discussions are needed.
While some staff may perceive this as taking up extra time, investment in this at an early stage in a baby’s life is likely to enhance the professional relationship and may prevent the need to “chase up” non immunisers later.
Healthcare professionals have a difficult role in balancing parents’ right to choose with the need to achieve universal childhood immunisation. However, there is considerable scope for improving immunisation information delivery. Central to this is the need to improve evidence based knowledge and the skill to communicate this effectively among healthcare professionals. This can and is being done locally by training and implementation of national standards. However, this knowledge needs to be delivered to parents in a way that supports their decision making.
Some parents may be happy with an information giving approach, but others need information tailored to their own needs. Healthcare professionals responsible for delivering immunisation information need a greater awareness of the different approaches available and how to adapt their advice accordingly.
Charles C et al (1997) Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine; 44: 681-92.
Cummins A et al (2004) Survey of local immunisation training in England - the case for setting national standards. Communicable Disease and Public Health; 7: 4, 267-71.
Department of Health (2010) Immunisation Against Infectious Disease - ‘The Green Book’. London: DH.
Department of Health (2009) Healthy Child Programme. Pregnancy and the First Five Years of Life. London: DH.
Department of Health (2004) Health Professionals 2004 Childhood Immunisation Survey. Executive Summary. London: DH.
Department of Health (2003) Building on the Best: Choice, Responsiveness and Equity in the NHS. London: DH.
Evans M et al (2001) Parents’ perspectives on the MMR immunisation: a focus group study. British Journal of General Practice; 51: 904-10.
Health Protection Agency et al (2005) National Minimum Standards for Immunisation Training. London: HPA.
Henderson R et al (2004) General practitioners’ concerns about childhood immunisation and suggestions for improving professional support and vaccine uptake. Communicable Disease & Public Health; 7: 260-6.
Hilton S et al (2009) Competency, confidence and conflicting evidence: key issues affecting health visitors’ use of research evidence in practice. BMC Nursing; 8: 4.
Jackson C et al (2008) A systematic review of decision support needs of parents making child health decisions. Health Expectations; 11: 232-51.
Kendrick D et al (2000) The effect of home visiting programmes on uptake of childhood immunization: a systematic review and meta-analysis. Journal of Public Health Medicine; 22: 1, 90-8.
McMurray R et al (2004) Managing controversy through consultation: a qualitative study of communication and trust around MMR vaccination decisions. British Journal of General Practice; 54: 504, 520-525.
National Institute for Health and Clinical Excellence (2009) Reducing Differences in the Uptake of Immunisations (Including Targeted Vaccines) Among Children and Young People aged Under 19 Years. London: NICE.
Petousis-Harris H et al (2005) Family practice nurse views on barriers to immunising children. Vaccine; 23: 2725-30.
Petrovic M et al (2001) Second dose of measles, mumps, and rubella vaccine: questionnaire survey of health professionals. British Medical Journal; 322: 82-85.
Raithatha N et al (2003) A qualitative investigation of vaccine risk perception amongst parents who immunize their children: a matter of public health concern. Journal of Public Health Medicine; 25: 161-4.
Redsell S et al (2010) Health visitors’ perception of their role in the universal childhood immunisation programme and their communication strategies with parents. Primary Care Research and Development; 11: 1, 51-60.
Redsell S, Buck J (2009) Health related decision-making: the use of information giving models in different care settings. Quality in Primary Care; 17: 6, 377-379.
Salmon DA et al (2005) Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study. Archives of Pediatrics & Adolescent Medicine; 159: 470-6.
Samad L et al (2006) Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. British Medical Journal; 332: 1312-3.
Serpell L, Green J (2006) Parental decision-making in childhood vaccination. Vaccine; 24: 4041-6.
Smailbegovic MS et al (2003) Why do parents decide against immunization? The effect of health beliefs and health professionals. Child: Care,Health & Development; 29: 303-11.
Smith A et al (2007) Tracking mothers’ attitudes to MMR immunisation 1996-2006. Vaccine; 25: 3996-4002.
Sporton RK, Francis SA (2001) Choosing not to immunize: are parents making informed decisions? Family Practice; 18: 181-8.
The NHS Information Centre for Health and Social Care (2008) NHS Immunisation Statistics England 2007-2008.
The NHS Information Centre for Health and Social Care (2005) NHS Immunisation Statistics, England: 2004-2005.
World Health Organization (2008) Routine Childhood Immunization Schedule: Recommendations from WHO Position Papers, 2008. Draft. Geneva: WHO.
Wroe AL et al (2004) Understanding and predicting parental decisions about early childhood immunizations. Health Psychology; 23: 33-41.