Tracking mothers attitudes to childhood immunisation 1991–2001

Vaccine 23 (2005) 5670–5687

Tracking mothers attitudes to childhood immunisation 1991–2001

Joanne Yarwooda,∗, Karen Noakesa, Dorian Kennedya,Helen Campbellb, David Salisburya

a Immunisation Policy, Monitoring and Surveillance, Department of Health, Wellington House, 133-155 Waterloo Road, London SE1 8UG, UKb Health Protection Agency, Immunisation Department, 61 Colindale Avenue, London NW9 5EQ, UK

Received 9 March 2004; accepted 25 November 2004Available online 23 September 2005

Abstract

This report presents the findings from a series of 20 surveys carried out between 1991 and 2001. The main objectives of the research wereto:

• obtain information on mothers’ knowledge of immunisation;• obtain information on mothers’ attitudes towards immunisation;•• rials.

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obtain information on mothers’ experience of immunisation services;monitor the recall and interpretation of NHS Immunisation Information (NHS II) advertising and immunisation information mate

This unique body of more than 15,000 interviews was conducted as part of a routine programme of research supporting thmmunisation programme in England. These surveys show that the public wants clarity, consistency, factual information and opehose delivering immunisation services.rown Copyright © 2005 Published by Elsevier Ltd. All rights reserved.

eywords: Immunisation; Mothers; Attitudes

. Introduction

The childhood immunisation programme in England aimso achieve and maintain high vaccine coverage so that no childeedlessly suffers from a vaccine preventable disease. As partf the programme parents must have appropriate support fromealth professionals and have information available to them

o make informed decisions.The immunisation programme in England has been highly

uccessful.Table 1shows the level of disease and death inhe UK from vaccine preventable diseases before and afterhe introduction of the relevant vaccines[1].

∗ Corresponding author.E-mail addresses: [email protected] (J. Yarwood),

[email protected] (K. Noakes), [email protected]. Kennedy), [email protected] (H. Campbell),[email protected] (D. Salisbury).

Even though immunisation is voluntary in England, cerage is generally high[2]. It has been estimated that o0.33% of parents do not consent to their child being incluin a computerised database that schedules immunisappointments[3,4].

Parental attitudes, experiences and social grade areential in determining whether or not a child receives a vacPersonal experience and knowledge of diseases influparental perceptions about the seriousness of diseasetheir likelihood of being affected by it[5].

In societies where immunisation programmes havesuccessful, the challenge is maintaining high levels of vaccoverage. In the absence of disease, the threat of that drapidly disappears and anxieties about the vaccine’s smay increase. A fall in vaccine coverage can lead to the rof disease as happened in the UK when rates of perimmunisation plummeted in the 1970s[6].

Beginning in 1991 the first of a series of surveysundertaken to track mothers’ attitudes and experienc

264-410X/$ – see front matter. Crown Copyright © 2005 Published by Elsevier Ltd. All rights reserved.oi:10.1016/j.vaccine.2004.11.081

J. Yarwood et al. / Vaccine 23 (2005) 5670–5687 5671

Fig. 1. Changes to the childhood immunisation programme since 1988.

immunisations and their recall of specific information mate-rials produced by the national immunisation information pro-gramme.

The main objectives of the research were to:

• obtain information on mothers’ knowledge of immunisa-tion;

• obtain information on mothers’ attitudes towards immuni-sation;

• obtain information on mothers’ experience of immunisa-tion services;

• monitor the recall and interpretation of NHS II advertisingand immunisation information materials.

Knowing what mothers already understand about immuni-sation and the diseases it protects against allows the Immuni-sation Information programme to produce materials that areaimed at the right level of knowledge and address mothers’concerns. The survey is an important opportunity to measure,twice a year, mothers’ recall of current information materialsand advertising and measure ‘external’ factors, for example,the effect of the media and other people’s opinions that influ-

Table 1Effect of vaccines on incidence of infectious diseases

Disease Before vaccination Baseline After vaccine use

DMMPPRCTH

ence their perceptions of the programme. Other factors suchas family history or the service provided are also examinedand the results used to influence future working, with eitherparents or health professionals.

By March 2001, 20 surveys had been conducted, rep-resenting over 15,000 interviews with parents. During thisperiod there were a number of changes to the nationalchildhood immunisation programme in England. The mainchanges are summarised inFig. 1and include the introductionof two new vaccines,Haemophilus influenzae type b (Hib)and meningococcal C conjugate (MenC) in 1992 and 1999,respectively, and the addition of a second dose of measles,mumps and rubella (MMR) vaccine in 1996. In 1994, therewas “one off” catch-up campaign with measles–rubella (MR)vaccine.

2. Methods

Twenty surveys among mothers of children under 3 yearsof age were conducted between October 1991 and March2001 (a complete list of fieldwork dates is given atAppendixA). The first seven surveys were conducted as part of thethen Health Education Authority’s wider ‘CommunicationsMonitor’. This project covered other health-related issues inaddition to childhood immunisations. From October 1994 ther

1000r se thep

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(n, annual cases) year (n, annual cases)

iphtheria 46,281 1940 4easles 409,521 1940 186umps 20,713 1989 175ertussis 53,607 1940 2996olio 1066 1940 2a

ubella 24,570 1989 99RS 73 1971 0etanus 19 1969 6ib 655 1989 56a Vaccine associated cases.

esearch was dedicated to childhood immunisation.In 1996, the sample size was increased from 500 to

espondents to minimise the sampling errors and increarecision of the survey estimates.

Annually the surveys cost less than 5% of the total bullocated to the programme of work delivered by the Imisation Information team.

In addition to the regular quantitative surveys thereeen:

5672 J. Yarwood et al. / Vaccine 23 (2005) 5670–5687

• qualitative research amongst mothers of children under 3years of age; and

• five separate surveys of mothers from ethnic communitygroups.

Findings from these other areas of research and the sub-sequent routine surveys will be published separately.

The mothers who took part were nationally representativeof those with children under three years of age. Face-to-faceinterviews were conducted in the home. The demographicprofile of the sample was weighted in terms of age, socialgrade and geographical location to match the profile of theoverall target group, based on national statistics.

Random location sampling was used[7]. The principaldistinguishing characteristic of this method is that interview-ers are given very little choice in the selection of respondents.Consecutive households were approached in approximately132 randomly selected enumeration districts, each constitut-ing around 150 households, until the full quota of motherswas obtained. As eligible mothers make up only approxi-mately 6% of the total population and the number of eligiblemothers in each enumeration district was not known, it is notpossible to estimate response rates. However, this techniqueensures a representative sample in terms of geographic andsocio-economic factors and the demographic profile of thesample (in terms of age, socio-economic grade of the chiefi tion).D ing tot

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based on mothers of children aged under 3 years of ageonly.

• The research was restricted to immunisation from October1994.

• In 1996 the sample size was increased from 500 to 1000respondents to minimise the sampling errors and increasethe precision of the survey estimates.

• The introduction of the CAPI interview (seeAppendix A)in March 1995 meant that the responses could be collatedmore accurately. It allowed more complex filtering of ques-tions used in the interview.

Findings are presented from all available data over the 10-year period. Initial data was collected as part of a wider surveyand not all of this information was subsequently available.Some questions were introduced after October 1991 and thisis reflected in the graphs.

3. Results

The tracking surveys have been conducted during an initialperiod of increasing uptake of childhood vaccines (Fig. 2a)[9]. In more recent years coverage has remained fairly stablefor most vaccines. The notable exception to this has beenMMR vaccine for which coverage began to fall graduallyf

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ncome earner in the household, and geographical locaata are weighted, using these characteristics, accord

he National Readership Survey[8].The questionnaire covered all aspects of the imm

ation process. Approximately, 100 questions were aaking about 45 min to complete. There were open-end closed questions, which required ‘spontaneous

prompted’ answers. The respondent is first asked to givnswer or answers without prompting, thus providing a mure of ‘top of mind’ issues. The respondent is then shoist of possible answers which may remind them of issuesad forgotten. The response to the open-ended questioecorded verbatim. Open text was ‘coded’ into categorieesponses at the analysis stage (seeAppendix A). For closeduestions, the response is recorded using a pre-coded a

ist.The need to provide data that is consistent and fa

ates fair comparison over time is of primary importan a tracking study. However, survey questions are conlly reviewed to ensure relevance to the current programome modifications to methodology and technology heen introduced to minimise any bias in responses way arise from the method of sampling used; the sa

izes achieved; the technology used to capture the respnd the way in which questions were asked. These arearised below:

From August 1992 only mothers with children undeyears of age were included in the survey. To direcompare data, figures from the first two surveys (wincluded mothers with children aged 0–5 years) have

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rom 1995 (Fig. 2b) [2].

.1. Spontaneous and prompted awareness of availablemmunisations

Respondents were asked what immunisations they there currently available for children. After answering sp

aneously, they were then shown a list of immunisationsrompted with the question “and which others of these immu-isations do you think are currently available for children?”

Fig. 3 shows the level of mothers’ spontaneous awess of childhood vaccines from October 1991 to M001. Awareness of MMR vaccine increased over theear period, polio and DTP vaccines remained relatitable while awareness of Hib and whooping coughines declined. Spontaneous awareness of MenC vahich was introduced in November 1999, showed a dram

ncrease in the short time following its introduction.The data for prompted awareness are not presente

how similar trends.

.2. Seriousness of diseases

Respondents were asked to rate how serious they feonsequences would be for children getting each of a nuf vaccine-preventable diseases, using the four point svery serious’, ‘ fairly serious’, ‘ not very serious’, ‘ not at allerious’. The proportion of mothers who rated the conuences of getting the disease as ‘very serious’ is shown inig. 4a and b.


Fig. 2. (a) The percentage of children completing their primary immunisations. (b) The percentage of children immunised with MMR by their second birthday.

3.3. Safety of immunisations

Respondents were asked to assess the safety of a numberof immunisations by rating them on a four-point scale: ‘com-pletely safe’, ‘slight risk’, ‘moderate risk’ and ‘high risk’.The results for “completely safe” or “slight risk” are shownin Fig. 5. Overall, respondents considered that all childhoodimmunisations offered a high level of safety.

Whooping cough vaccine was least likely to be consideredsafe by mothers up to August 1997, after which time it wasdisplaced by MMR. A gradual decline in the perceived safetyof MMR was apparent from 1994.

Since February 1997 respondents were asked whetherany immunisations carried greater risks than the diseasesagainst which they protect. The results are shown inFig. 6.

re spon
Fig. 3. The percentage of mothers who we taneously aware of individual childhood vaccines.


Fig. 4. (a) The percentage of mothers who said the consequences of getting the disease would be ‘very serious’. (b) The percentage of mothers who said theconsequences of getting the disease would be ‘very serious’.

Up to 1997 whooping cough was the vaccine most likelyto be identified as carrying a greater risk than the diseaseit protected against. After that time, MMR was the vaccineover which the greatest percentage of mothers’ expressedconcern.

3.4. Immunisations mothers would not allow a futurechild to have

Respondents were asked if there were immunisationswhich they would not allow a future child to have, and ifso, which.Fig. 7shows the responses over time.

Mothers were also asked whether they agreed or disagreedwith the statement “If I had another child, I would have themimmunised against all childhood diseases”. Fig. 8shows theoverall proportion of mothers ‘agreeing’ (i.e. ‘strongly’ and

‘ tend to’ combined) and those ‘strongly agreeing’ with thisstatement over time.

3.5. Interactions with health professionals

Respondents who accompanied their child on their mostrecent immunisation visit were asked whether they hadreceived any information or advice from any health pro-fessional before their children were due to be immunised(responses over time are shown inFig. 9). They were alsoasked about the nature of that information and their levels ofsatisfaction with their most recent immunisation visit.

Over the period of the surveys, at least two-thirds ofrespondents discussed immunisation with a health profes-sional before their child was immunised. Around a half dis-cussed immunisation with a Health Visitor. The majority of


Fig. 5. The percentage of mothers who believed that individual immunisations were ‘completely safe’ or involved a ‘slight risk’.

mothers who discussed immunisation with a health profes-sional were told about both the benefits and side effects ofvaccines. Less than a quarter of respondents reported beingtold only about the benefits, and less than a tenth reportedbeing told only about the side effects.

Respondents were asked whether they had discussed theside effects of immunisation with anyone else (Fig. 10).From 1999 onwards, marked changes were seen, as hus-band/partner became the key contact and the influence ofother family members declined. This may suggest that fathers

are taking an increasing role in their children’s immunisation,perhaps in association with the rising concern over MMR.

3.6. The immunisation visit

A high proportion of respondents were completely satis-fied with their most recent immunisation visit. Although upto 31% of respondents had claimed to be dissatisfied withsome aspect of their most recent visit, only up to 9% said thatthey were dissatisfied ‘overall’ (seeFig. 11).

y immu t.
Fig. 6. The percentage of mothers who considered that an nisation presented a greater risk than the disease it protected agains


Fig. 7. Immunisations mothers would not allow a future child to have.

3.7. Advertising and publicity

The survey has tracked the impact of several television-advertising campaigns. Some of these campaigns aredesigned to increase awareness of immunisation in gen-eral, whilst others were specific to particular immunisations.These are briefly described inAppendix B.

Mothers were asked whether they had “heard or seen anyadvertising, information or publicity about immunisation forchildren in the last 12 months”, and if so, to specify wherethey had seen it.Fig. 12 shows the proportion of motherswho recalled spontaneously that they had seen or heard anyadvertising, information or publicity about childhood immu-nisation.

A large proportion of respondents recalled that they hadseen something and the two most frequently mentionedsources were television advertisements and leaflets (Fig. 12).

3.8. Prompted awareness of television advertising

For an explanation of TVRs seeAppendix B.Both the ‘Ring-a-Roses’ and “Babies” campaigns

achieved consistently high levels of awareness. The ‘MenC’campaign rapidly achieved a high level (71%) of recognition(Fig. 13).

3.9. Prompted awareness of leaflets

Fig. 14 shows prompted recall of leaflets.Appendix Ccontains a short description of different leaflets.

The recall shown here is considered to be high. Most ofthe mothers would have been given a copy of the Guide toChildhood Immunisations (the main leaflet) during the post-natal visit from the Health Visitor at around 10 days after thechild’s birth.

sations
Fig. 8. Immuni of a future child.


Fig. 9. The health professionals with whom mothers discussed immunisation before their child’s immunisations were due.

Fig. 10. Other people with whom mothers discussed the side effects of vaccines before their child’s immunisations were due.


Fig. 11. Any dissatisfaction with immunisation visit.

An increase was seen in the awareness of all leaflets from1999, reflecting the higher public interest in immunisation.

3.10. Prompted awareness of press advertisements andposters

Mothers were shown pictures of several advertisementsthat were placed in the press, and posters provided for doc-tors’ waiting rooms, and asked if they recalled seeing them.The results are shown inFig. 15.

3.11. Attitudes to advertising

After mothers had been shown the advertising materialsthey were offered a number of attitude statements to measuretheir opinions of the advertising. They were asked to respondto the statements:

• “this advertising made me feel more confident about thesafety of childhood immunisations”** ;

• “this advertising made me realise that some childhood dis-eases are more serious than I thought”** ;

ertising months.
Fig. 12. The proportion of mothers who had seen or heard any adv , information or publicity about childhood immunisation in the last 12


Fig. 13. The prompted recognition of television advertising.

• “I don’t take notice of advertisements like these”;• “this advertisement reminded me of the importance of

childhood immunisations”** ;• “this advertising made me feel confident about discussing

immunisations with my doctor”** ;• “this advertising confused me about which immunisations

my child should and shouldn’t have”.

Results for those mothers who ‘strongly’ or ‘ tend toagree’ with the four positive statements (** ) are shown inFig. 16. The results show the impact of advertising andits important role in acting as a prompt for immunisa-tion.

4. Discussion

Other knowledge, attitudes and behaviour studies havebeen carried out previously[10,11]. However, the datareported here is unique in the extent and number of eachset of interviews and the length of time the series has been inplace. The value of this long-term survey lies mainly in:

• assessing the needs and understanding of mothers aboutdiseases, vaccines and vaccination;

• assessing the role of health professionals;• understanding the impact of other sources of information

on the programme, e.g. the media;

lled lea
Fig. 14. The percentage of mothers who reca flets when prompted with a picture of the front cover.


Fig. 15. The prompted recall of press ads and posters.

• analysing the impact of high investment activity such asadvertising on respondents;

• strategic planning for future campaigns and programmes;• giving parents a real “voice” in the development of the

immunisation programme and immunisation informationmaterials in England.

A better understanding of issues outlined above meansthat the programme can be planned to provide parents

and health professionals with the information they needto better understand the facts and to counter scare sto-ries.

This work is a sensitive tool to track influences on immuni-sation programmes and serves as an indicator for early trendsin coverage. Comparisons made between this survey and cov-erage data at 16 months show similar trends over time[12]and that parents’ fears over vaccine safety are reflected byuptake data.

Fig. 16. Attitudes to advertising: the percentage of mothers that ‘strongly’
agreed or ‘tended to’ agree with statements about the immunisation materials.


The results from this tracking survey show trends in moth-ers’ attitudes to immunisation which are recorded quantita-tively (n = 1000). They do not allow for an in-depth analysisof mothers’ views and understanding of the immunisationprogramme. Qualitative research is carried out separately.

Interviews are carried out during the day with the per-son who is the primary carer for the child. Some possiblebias may be introduced as mothers who are working may beunder-represented but this is unlikely to introduce significanteffects. A further limitation to the study, as with any door-to-door survey, is that only the views of those willing to beinterviewed are sought and may introduce some bias to theresults. However, the longitudinal nature of the study and theconsistency with other study results suggest that these find-ings are representative of the views of mothers in England.

This series of surveys measured five factors that werelikely to affect mothers’ behaviour when deciding whetherto immunise their children:

• awareness of vaccines;• how serious they believed the disease was;• how safe they believed the vaccine to be;• their experience of the service offered;• the information they were able to access.

4.1. Awareness of vaccines

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cine was incorporated into DTP as a combined injection. Theinitial increases in awareness for Hib (and MenC) vaccineprovides good evidence of the success of the advertising andmedia campaign surrounding the introduction of the immu-nisations.

Spontaneous awareness of whooping cough vaccine fellmarkedly over the 10-years. Although whooping coughimmunisation had been the focus of a high profile vaccinescare in the 1970s and 1980s it did not attract any media atten-tion or publicity during the period of this tracking study. FromSeptember 1999 onwards the level of spontaneous aware-ness of DTP vaccine began to increase slowly. The increasedawareness of DTP vaccine may be due to publicity surround-ing mercury-containing vaccines. DTP was the only vaccinein the routine childhood programme to contain the mercury-derivative thiomersal.

The fluctuations in spontaneous awareness of these immu-nisations and their close association with high levels ofpublicity show the powerful effect of the media on the under-standing of and response to health ‘scares’[17,18].

An increase in the spontaneous awareness of vaccines (seeFig. 3) can be an important measure of the success of pub-licity, as seen with the introduction of Hib vaccine (1992),MenC vaccine (1999) and the MR campaign in 1994.Fig. 12shows that television advertising was the key driver of spon-taneous awareness of any form of advertising or publicity. Fore mu-n ’ or‘

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The peak of spontaneous awareness of MMR in M995 followed both a national immunisation campa

o protect children against measles and rubella[13], andpaper being published that suggested a link betw

easles vaccine and inflammatory bowel disease (14]. From that time on measles-containing vaccines beche subject of, at times, intensive media attention. Sugust 1996 MMR has attracted the highest level of pare

ecall (with the exception of October 2000, when theenC vaccine was introduced). Over 70% of mothers w

onsistently aware of MMR vaccine without promptin this period. Further peaks reflect the publication oaper linking MMR with bowel disease and autism[15]

n 1998, and high levels of media interest in MMR001.

The high awareness of polio vaccine in 2000 coincith publicity surrounding the withdrawal of one brandolio vaccine. The vaccine was withdrawn as a pre

ionary measure as the manufacturer had used UK-soovine material at a very early stage of the vaccine pro

ion, which was inconsistent with Committee on Safetyedicine guidelines. The media linked this use of particovine material with BSE[16] and undoubtedly this causn increase in spontaneous awareness of polio vaccine

ime. However, the media publicity was short lived and spaneous awareness had fallen by March 2001.

Spontaneous awareness of Hib vaccine rose steeplyhe immunisation was introduced but declined after thedvertising campaign ended, and especially once Hib

t

xample, over 80% of mothers recognised the generic imisation advertisement of the time (either ‘Ring-a-roses

Babies’ campaigns).As would be expected, awareness rose during or

fter a television advertising campaign had run, and drohen advertisements had not been shown. As a resas decided to run TV advertisements more frequently998. This has resulted in fewer fluctuations in the levewareness.

Mothers’ positive attitudes to advertising materials heen consistent over the period of the survey. The m

ty of mothers agreed that advertising reminded them omportance of childhood immunisations and the seriousf vaccine-preventable diseases. However, the likelihooothers agreeing with positive statements towards the cood immunisation advertising has decreased over time

s consistent with the gradual decline in public confideeen elsewhere in the survey resulting especially from recares about MMR vaccine.

High awareness of a specific immunisation can be aive measure of a targeted advertising campaign, for examith the introduction of Hib and MenC. However, high awaess can also reflect negative perceptions of immunisahis can be seen with the sustained high measure assoith MMR vaccine, and the temporary peak associatedolio vaccine in October 2000. The findings highlight tnowledge of the current environment is important wsking questions about immunisation as high awareay correlate with, for example, high levels of me

overage.


4.2. Seriousness of disease and safety of vaccines

Over the entire period of this survey, more than 90% ofrespondents believed that catching meningitis would be veryserious for their child. The perceived severity of measles,mumps and rubella, remained low apart from the markedincrease in 1994 as a consequence of the MR campaignand the associated advertising. Between March 2000 andMarch 2001 there was an increase in the number of motherswho rated measles and mumps and rubella as ‘very serious’diseases, coinciding with reports in the media of measles out-breaks[19]. Despite this, these diseases remain as the lowestrated of the diseases for which protection is offered.

Soon after Hib immunisation was introduced, the percep-tion of Hib as a disease with very serious consequences roserapidly and peaked in December 1993, probably as a conse-quence of the campaign and the associated advertising.

Understanding the range of concerns and their influenceson parents’ decision-making helps to ensure that the infor-mation materials are tailored to parental need.Figs. 4 and 6together show that the perceived safety of the vaccine is inde-pendent of the perceived severity of the disease. This suggeststhat mothers are more strongly influenced by the perceivedrisk that a vaccine carries, rather than balancing overall therisks and benefits of vaccinating against those of not vacci-nating.

4

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Fig. 17. Influence of the fear of a vaccine versus the fear of disease onthe decision to immunise. Source: Salisbury, DM. The consumers perspec-tive. In: de Quadros CA, editor. Vaccines–Preventing Disease and ProtectingHealth. ISBN 9275115866.

illustrates how long it can take for public confidence in avaccine to return after a high profile media scare.

Even so, over the period of these surveys, more than 90%of the respondents agreed that they would have another childimmunised, apart from in one survey in 1998. This is in closeagreement with measured coverage for the infant immunisa-tion programme and suggests that it is a good indicator ofparental behaviour.

In our surveys polio vaccine followed most closely to an“ideal” vaccine model: the vaccine was most likely to be con-sidered safe and polio was considered a serious disease. Poliois the only endemic childhood disease, other than smallpox,to have been eliminated from Europe and therefore carries anegligible risk of natural infection. However, oral polio vac-cine is the only childhood vaccine to have a proven risk of aside effect with permanent sequelae (vaccine associated par-alytic polio VAPP) although the overall risk is less than 1in a million. It is possible that polio vaccine was perceivedto be safe, and had a continued high level of spontaneousawareness, because it is administered orally.

MMR protects against diseases that were generally notconsidered to be serious. It was also the vaccine least likelyto be considered safe. These observations influence why somemothers may choose not to have their children’s immunisedwith MMR vaccine. This insight into parental behaviour hasbeen demonstrated by comparing MMR vaccine coverage at1 ty oft ds encea

.3. Taking action

The “ideal” is where the parent believes a vaccine tafe and a disease serious. In this case, it is likely thaarent will act and immunise the child (seeFig. 17). Where aarent has no fear of either the vaccine or the disease th

ikely to follow recommendations to immunise their chhen this appears to be the societal norm. If parentsoncerns about the safety of a vaccine, and believe a dis not serious, then they may refuse vaccination. Howome parents are presented with a dilemma if they behat the vaccine is unsafe and the disease is serious. Iituation parents are likely to become increasingly afnsure of what action to take and who to trust.

Fig. 6shows that some mothers said that there was atne vaccine that they believed carried a greater risk thaisease/s it protected against. Up to 1997 more mothersidered whooping cough immunisation to carry a greatehan others. In the UK, whooping cough was the first chood vaccine to experience a high profile ‘scare’ in re

imes, when a link with serious neurological conditionsroposed[20]. Whooping cough was the vaccine least lik

o be considered safe by mothers when the tracking stegan, even though it had been more than 10 years sincerns about the vaccine had been shown to be unfounded[21].he perceived risk associated with the vaccine has decver the period of these surveys, and spontaneous awaf whooping cough vaccine also declined from the secost likely to be recalled, to one of the least likely. T

s6 months of age with tracking data of perceived safe

he vaccine and is shown inFig. 18 [12]. These data showeimilar trends and correlate the decline in parental confidnd coverage since late 1997.


Fig. 18. MMR uptake at 16 months and proportion of mothers believing incomplete or almost complete safety of MMR vaccine.

Despite media-based stories, in particular those surround-ing the MMR–autism link, the percentage of respondents whowould not immunise a future child remains below 10%. Theimpact of the media can clearly be seen in the increase inMMR specific concern in 1998 and 2001 (seeFig. 17).

While confidence in MMR declined during the periodcovered by this report due to concerns about links to inflam-matory bowel disease and autism, earlier concerns about thevaccine did not have the same effect. For example, confidencein the safety of MMR vaccine remained high throughout1992, the year when MMR vaccines containing the Urabemumps component were suspended in the UK because of alink to aseptic mumps meningitis. This suggests that mothers’assessment of the perceived risks of vaccines and diseases dnot coincide with a scientific based risk assessment. Exam-ination of, for example, media coverage shows the level ofinterest to have been much lower in the Urabe issue than thepurported links between MMR, autism and bowel disease.Interestingly a real risk attracted much less coverage than aputative and unproven risk.

4.4. Experience of the service offered

Parents’ attitudes and beliefs are an important influence ofwhether or not they chose to accept immunisations for theirchild. However, the 1989 Peckham Report considered thatp d bye fromfs abouc vac-c ers,h cant

minority of the nurses believed that MMR vaccine was verylikely or possibly associated with Crohn’s disease or autism[22]. This raises some concerns given the recent debate overMMR and the reliance that parents place on advice fromhealth professionals. About one in five GPs in this surveyadmitted that they had not read centrally provided materialon MMR vaccine.Fig. 9 shows that most mothers discusssome aspects of their children’s immunisation with a healthprofessional before immunisation takes place. For about 50%of mothers the initial discussion will be with their health vis-itor soon after the baby is born. In addition, parents are mostlikely to see a practice nurse when their children are immu-nised[23]. This highlights the role of health professionals andthe importance of the information they provide to parents.

The majority of mothers were told about the benefits andside effects of immunisation. A significant minority said thatthey were only told of one or the other. While selective recallmay contribute to this finding it is important that health pro-fessionals give balanced information. There was, overall, ahigh level of satisfaction with the most recent immunisationvisit (seeFig. 11). This has remained fairly constant through-out the 10-year period. Most of the reasons given for anydissatisfaction are linked with the lack of opportunity to askquestions and the time allocated in the clinic setting.

The shift in recent years of the kind of issues that arediscussed, and with whom those discussions take place, isv outs andsa s theso at thei nalsa ftt at the1 mu-n earo n, ash ce ofo thersa ion,p R.

icsa tiona hersn oth-e r dis-c ers’c t ont eene ntialt con-c Thus,i cticei theyd llows ce.

arental perceptions of immunisations could be modifiexternal influences such as health education or adviceriends, family or health professionals[19]. It also found atrong association between the knowledge that GPs hadontraindications for measles and pertussis vaccine andine uptake. A more recent survey of general practitionealth visitors and practice nurses found that a signifi

o

t

ery important. Mothers are now more likely to talk aberious perceived “side effects” with their partners, husbnd friends, including the more alarming issues such auggested links between MMR and autism (Fig. 10). Theynly tend to discuss issues such as fever and soreness

njection site (proven side effects) with health professios shown in wave 20 (seeFig. 19). This is an important shi

hat also emphasises the importance of the discussion0-day visit and the value of continuing discussions on imisation at all contacts with the family during the first yf life. From 1999 onwards, marked changes were seeusband/partner became the key contact and the influenther family members declined. This may suggest that fare taking an increasing role in their children’s immunisaterhaps in association with the rising concern over MM

Monitoring mothers’ experience of their visits to clinnd surgeries shows that while overall levels of satisfacre high, the time available in the clinic can influence motegatively. Unsurprisingly, dissatisfaction rises when mrs do not feel that enough time has been available foussion. While immunisation rates are high and mothonfidence is high, this may not have a negative effeche uptake of immunisation. However, if confidence has broded, as may have happened with MMR, then it is esse

hat mothers feel that they have the opportunity to raiseerns and that those concerns are properly addressed.t is important that health professionals assess their pran the light of such information. They should ensure thatiscuss all aspects of immunisation with mothers, and aufficient time in the clinic for that discussion to take pla


Fig. 19. Side effects discussed. Base: All mothers of 0–2s who discussed side effects Wave 20.

4.5. Publicity and access to information

Advertising and publicity can play an important role inreaching a wide audience, in reinforcing long-term messages,and also to inform people of important changes in the pro-gramme. The costs attached to TV and press advertising arehigh and thus it is important to monitor the use of such tools.This survey shows that advertising does effectively remindmothers of the importance of immunisation in the routinesetting. It is an important mechanism in the introduction ofnew vaccines, e.g. MenC in 1999, changes to the schedule,vaccine controversies or maintenance of the programme. Pro-longed recall of advertising shows the powerful impact thatsuch work has and further supports its use.

After TV advertising, leaflets were the second most fre-quently mentioned source of information. Leaflets are oftenstill available in health centres and doctors surgeries formonths or years after their publication. The overall rise inthe awareness of “any leaflet” seen in 1999 may have beendriven by the high and positive profile of the MenC cam-paign. Recognition of the ‘Big Baby’ poster in GP surgeriesgradually increased over the period of the survey.

Fluctuations in the awareness of TV ads closely matchedthe presence (or absence) of advertising. Mothers’ awarenessof leaflets did not show such marked fluctuation owing to thecontinuous availability of these information materials.

5

care-f ofu cines.

There is little doubt currently that controversy will oftenattach to immunisation programmes[24]. The users of theprogramme, including parents, children and health profes-sionals have specific information needs, each of which needsto be addressed.

For an immunisation programme to be successful, invest-ment has to be made in ensuring that the information isaccessible, transparent and understandable to the public. Thismay be particularly so in countries where immunisation pro-grammes have achieved high coverage rates over a numberof years, and hence low rates of disease. In this case, thereis a tendency for greater concern about vaccine safety ratherthan the diseases they prevent[25]. Thus, any perceived riskassociated with the vaccine gains greater influence as thememory of the disease fades. Vaccine safety is then morelikely to influence parents’ decisions on whether or not toimmunise their children.

Analysis of results from these surveys, and results fromother qualitative analytic methods used regularly by theDepartment of Health, shows that the public wants:

• clarity;• consistency;• factual information;• openness;• and different routes to be used for delivering information.

ionb

••••

. Conclusion

Immunisation programmes are complex and requireul long-term planning to ensure continued high levelsptake of established vaccines and to introduce new vac

Mothers turn to many different sources for informatut there appear to be four main ones:

health professionals;friends, family and spouse/partner;leaflets;advertising (TV most prominently).


The results demonstrate the importance mothers put onopportunities to discuss immunisation with health profes-sionals. The health visitor in particular is the person theyare most likely to have this discussion with. This is influ-enced by the post-natal visit, and Health Visitors continuedinvolvement with mothers with young infants. In more recentyears mothers have also identified the midwife as influential:questions about immunisation, possibly driven by high mediaattention, spill forward into the antenatal period. The role ofthe GP and practice nurse is also recognised.

Our results suggest mothers are more strongly influencedby the perceived risk that a vaccine carries, rather than bal-ancing the overall risks and benefits of vaccinating, againstnot vaccinating. This may be because mothers are no longeraware of the risk of disease or have difficulty assessing risks.

The results presented in this report have allowed thenational programme in England to develop informationresources that meet the needs of parents. It shows, in smallpart, the effect of lay constructs on health understanding[26].Material must be accessible not only to those who are directlyinvolved but also the wider community to explain the impor-tance of immunisation.

The investment in research made by the ImmunisationInformation programme of the Department of Health in Eng-land is high. This reflects the importance attached to ensur-ing that parents’ concerns are heard and addressed. Theirc t thed thisw thusc

Ac

W

11111111112

eys.

Seriousness of childhood diseases.The safety of the immunisations.Whether mothers felt any immunisations presented a greaterrisk than the disease or diseases they protected againstHow likely mothers would be to immunise their children ifcertain new vaccines became available.Information about childhood immunisations.• Sources of information mothers used.• Where they got it from.• What were they advised about in their discussions with

health professionals.• Who else they discussed these issues with.• Whether they felt they had made a definite choice about

whether or not to have their children immunised.• What would be their ideal sources of information.Mothers’ most recent immunisation visit.• Who they had seen.• What their child was being immunised for.• Whether they were asked to give consent to have their

child immunised.• Aspects of satisfaction or dissatisfaction with that visit.

The final section covered advertising and immunisationmaterials. Respondents were prompted with a number of theadvertising materials and publications and asked a numberof questions about them to measure recognition, impact andi

mores

n orp

per-

erep how-c s ofs ther stionsa tera t thatt ents( uter.T iona morea on ofm intoa tionoH per-s iona gni-t t bee

oncerns will then influence the decisions made abouelivery of the immunisation programme in England. Inay, the programme can be developed responsively andontribute to the protection of children in England.

ppendix A. Fieldwork dates for the surveysonducted between 1991 and 2001

ave Fieldwork Dates

1 11–31 October 19912 27 March–3 April 19923 28 August–10 September 19924 27 November–10 December 19925 15–28 March 19936 3 December 1993–4 January 19947 1–14 April 19948 24 October–6 November 19949 13–26 March 19950 26 February–3 March 19961 19 August–1 September 19962 22 February–14 March 19973 22 August–19 September 19974 23 February–14 March 19985 21 September–18 October 19986 23 March–11 April 19997 16 September–5 October 19998 13 March–31 March 20009 16 October–8 November 20000 12 March–1 April 2001

Summary of areas of questioning included in the surv

Number and ages of interviewees children.Awareness of childhood immunisations.

dentify where the materials were seen.Advertising about health issues in general and then,

pecifically, childhood immunisations.Whether they had seen any advertising, informatio

ublicity about childhood immunisations:

• where they had seen it;• whether it was helpful; and• whether they had seen anything that might have

suaded them not to immunise their children.

In the first 19 of the 20 surveys, respondents wrompted with advertisements and materials using sards or telepics. A picture of the leaflet, or a serietills from the television advertisement were shown toespondent and they were than asked a series of quebout it. However, in March 2001, multi-media compussisted personal interviewing was used. This mean

he respondent was played or shown the advertisemincluding sound) on the screen of the lap-top comphe measurement of recognition (particularly of televisdvertisements) taken in March 2001 may have been accurate measurement. In other studies, the introductiulti-media computer assisted personal interviewingdvertising tracking surveys has generally led to a fluctuaf prompted recognition of advertisements of±20% [27].owever, the effect of multi-media computer assistedonal interviewing is generally only applicable for televisdvertisements. Similar fluctuations of prompted reco

ion of leaflets, posters and other publications would noxpected.


Appendix B

‘Childhood diseases haven’ t died’ (October 1991 toMarch 1992): This was a generic immunisation campaign,which aimed to highlight the fact that a number of poten-tially fatal childhood diseases were still in existence, and thatimmunisation can protect against them. The campaign useda combination of television, press and posters.

‘Hib’ (October 1992–March 1993): This was a spe-cific campaign which introduced the new Hib vaccine, andexplained what it could protect against. The campaign fea-tured children playing with dolls, and ran on both the televi-sion and in the press.

‘Ring-a-roses’ (March 1994–January 1997): A genericcampaign which featured children playing ‘ring-a-roses’ andran on both the television and in the press.

Measles (October–November 1994): A measles alert cam-paign which ran on TV, national press and leaflets in orderto promote the MR campaign that targeted all children aged5–16 years of age.

‘Babies’ (January 1998–September 2001): A genericadvertisement that featured a baby in dangerous situations.

Meningitis C (November–December 1999): A specifictelevision and poster campaign for the introduction of theMeningitis C vaccination.

Television advertising has centred on several key cam-pr r tom spond am-p ent.H sedt ediaC evi-s d bes lev-e uredu hanu s ise ediaC

e ofw ism rgeta nce,i 5%o addedt eightso

2 ver3 r+

t willh

Appendix C

A short summary leaflet and main leaflet that both coveredthe primary childhood immunisation programme (childrenaged approximately 0–18 months) were launched in October1996. Their Health Visitor gives the main leaflet to all mothersat their 10-day postnatal visit. The summary leaflet is a briefleaflet that summarises this information and is available asa reminder to mothers as and when necessary. Up to March1999, 37% of mothers recognised the main leaflet and 26%the summary leaflet. Recognition of both of these leafletsincreased substantially in September 1999 and March 2000reaching 71% and 51%, respectively, and this was the mainfactor in the increase in awareness of ‘any’ leaflet. It was notclear what drove this increase. From March 2000 recognitionof both leaflets began to decline and by March 2001 was 51%and 29%, respectively.

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t N.r-city

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[ influ-im-

[ er-trics

[ ntalence

Pract

[ rownales17–

[ . Isase?

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Documents

Tracking mothers attitudes to childhood immunisation 1991–2001