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Background
In Ireland, vaccination services are organised through ten health boards.
The Southern Health Board (SHB), where this study occurred, is situated
in the south-west of the country, and is composed of two counties (Cork
and Kerry). It has a population of 580 605 (2002) and a birth rate of
13.97/1 000 population (2001) (1). Family doctors (called general practitioners,
GPs) are contracted by the government to provide primary childhood vac-
cination services in their practices. Vaccinations are recommended but
not mandatory (see Table 1 for schedule of early childhood vaccinations).
Parents are usually informed about the vaccination process and schedule
by public health nurses, GPs or practice nurses, and midwives in maternity
hospitals. Until recently, local health board information was predominantly
limited to provision of leaflets or posters in clinics, but after the
measles outbreak in 2000, the media was used extensively to alert and
remind parents of the importance of vaccination.
Reported vaccine uptake levels are low in Ireland. Figure 1 shows the
uptake levels at age 24 months since 1999. Uptake of MMR improved somewhat
during 2000, probably related to publicity and concern about an outbreak
of measles with more than 1600 cases and three deaths reported to the
Irish National Disease Surveillance Centre (NDSC). Most cases occurred
among unvaccinated children. However, in 2001 the uptake again declined
and reached a low of 69% in the fourth quarter of 2001.
Vaccination rates fall can be derived from diverse and complex reasons.
In recent years a number of outbreaks have been reported in under-vaccinated
populations throughout Europe (3-5). Anecdotal reports in the SHB region
suggested that the decrease in vaccination coverage with three doses
of DTaP/Hib/Polio and one dose MMR (approximately 74% during the third
quarter of 2001) was linked to parental concerns about vaccine safety
(particularly MMR vaccine). This followed extensive media coverage of
an alleged link between MMR vaccine and autism or inflammatory bowel
disease. To date, all the expert reviews of the literature and population
studies have refuted such association (6).
Although much has been published in the international literature on
knowledge, attitudes and practices (KAP) regarding vaccinations, few
such studies have been published about KAP among Irish parents or health
professionals (7,8). Although there have been a number of recent studies
undertaken in this area in the academic settings, most have used quantitative
methods (9,10). The Department of Public Health in the health board
undertook this study to more clearly determine the knowledge, attitudes
and practices of parents and health professionals in Cork and Kerry
to early childhood vaccines.
Methods
The study was undertaken between May and August 2001 and involved both
qualitative (interviews, focus groups) and quantitative methods (surveys).
Only the qualitative results of the study are presented here. Initial
semi-structured telephone interviews with key informant GPs (ie GPs
involved in post-graduate training) identified those reasons that they
considered responsible for falling vaccination rates. The issues and
concerns expressed were then further explored in focus group discussions
with parents and nurses (public health nurses, practice nurses and midwives).
Non-probabilistic sampling methods were used for selecting participants
for the focus groups. Coordinators of 'mother and toddler' groups known
to the SHB or other organisations involved in child health (e.g. La
Leche League) were informed of the study and asked to invite participation
from their members (i.e. parents). Senior Public Health Nurse Managers
and hospital matrons in each hospital providing obstetric services were
similarly contacted, and asked to identify and invite participation
of staff involved in providing or advising on child health care. Local
branches of the Irish Practice Nurse Association were contacted and
invitations extended to their members to participate.
Eight focus groups were held with parents (47 participants), 3 focus
groups with public health nurses (23 participants), two focus groups
with midwives (14 participants), and two focus groups with practice
nurses (12 participants). The groups were formed to represent a broad
range of parents from different socio-economic and geographical areas,
as well as health professionals, using methods appropriate for qualitative
research (11).
A facilitator and a scribe who noted the comments of the participants
attended focus groups. The analysis and write up was conducted by another
independent researcher. The notes from the focus groups were transcribed
and analysed by content in accordance with recognised qualitative research
techniques (12). The transcripts for each focus groups including the
various types of participants (parents, practice nurses etc.) were read
through and analysed separately to identify emergent key themes and
issues, which were then coded. Care was taken to consider minority opinions
as well as the majority viewpoint (13,14). Emergent themes and main
issues were later compared with those identified independently by the
group facilitator.
Results
Interviews with 19 GPs from Counties Cork and Kerry were organised between
April and June 2001. The 15 focus groups with nurses and parents were
held between May and August 2001.
Parental knowledge and attitudes
Although most parents participating in the focus groups had had their
children vaccinated (only 3 of 47 parents reported that none of their
children had been vaccinated), they still expressed fear, mistrust and
dissatisfaction with the information provided about vaccines. Particular
concern was expressed about MMR vaccine, most of which appeared to have
been generated by local and national media reports and concerns expressed
among friends and relatives.
Fear and uncertainty
Parents feared vaccine side-effects and were particularly concerned
about the alleged side-effect of MMR to cause autism or inflammatory
bowel disease. Media and hearsay strongly influenced these fears and
created uncertainty, even when reassurance was given to them from health
professionals.
'I had terrible fear about giving the MMR… The doctor said that
there's no scientific proof…but people are still saying it..' (parent)
Mistrust
Parents expressed a mistrust of the health services, in what they were
told about vaccines and what they felt they were not being told. 'You
feel that everything that is adverse is hidden under the carpet'. Much
of the mistrust appeared to be generated by publicity covering government
inquiries on contaminated blood supplies, 'scares' related to use of
out-of-date vaccine and vCJD donors to plasma components used in vaccine
manufacture. 'If all these things are coming out... it makes you wonder
what is not coming out? How long would they have waited to tell you'.
Population versus individual health needs
Parents were concerned about the population health approach adopted
by the health services. Many felt that health professionals did not
sufficiently consider the well-being of their child as an individual.
'The impression you get from the health board…willing to have one
autistic child rather than an outbreak…but when it is your child…'.
'Your thing is the population…that's your job…you don't see
us as flesh and blood.
Parents appreciated a one-to-one approach between the health professional
and child/parent. They expressed satisfaction when their GPs took the
time to listen to their concerns and advised them on expected reactions
or checked back to see if the child was all right. '...The way she talked
me through it… and we vaccinated in the morning and then I came
back in the afternoon and he was checked … it was very good' (mother
of child who previously had reaction to vaccine)
Information
Most parents were poorly informed about the diseases that their children
were being vaccinated against. They felt they were given insufficient
or conflicting and confusing information about vaccines and vaccine
preventable diseases. 'We need to know the risks… they tell you
it's better to give than not … but they don't tell you why…'
Parents were reassured when they felt they were informed and more in
control of their decision-making. ' I knew what to expect because my
GP told me… if he hadn't told me I would have been calling him…it's
just having information…what to expect…'
Health professionals' views
It was clear from the focus groups (nurses) and interviews (GPs) that
there is widespread parental fear of vaccines and a mistrust of health
services and 'the authorities'. In general, health professionals perceived
parents in Cork and Kerry to be both confused about, and have limited
knowledge of, vaccines and vaccine preventable diseases.
The study also revealed that the levels of knowledge about vaccines
and vaccine preventable diseases varied greatly both within, and between,
the different health professional groups. Those that were less involved
in vaccination were less informed, expressed more vaccine related concerns,
and appeared to be more influenced by the media and less likely to be
strong advocates of vaccination.
To varying degrees, the health professionals felt that they were ill-equipped
to properly inform parents about vaccine related issues, citing insufficient
time, lack of user-friendly information or absence of critical information
when needed (e.g. during vaccine scares when they are the first line
responders). They all expressed a need for timely and accurate information
to help them address parental concerns.'We need up-to-date information
and research…if health professionals had better information they
would be better able to promote'.
All the health professionals considered that the influence of the media
had had a dramatic negative impact on vaccination rates: 'Biggest problem
is adverse publicity in the press'.
GP practice staff (GPs and practice nurses) in particular reported that
more time was needed to alleviate parental concerns generated by media
scare stories. Similar findings were identified in a survey of GPs in
the region (data not presented here) : 'Takes more and more time to
do vaccinations'.
Discussion
Improving vaccination coverage requires an understanding of why children
are not being vaccinated. Previous studies in Ireland have shown that
low vaccination rates are in part attributable to underestimation (9),
or that parents are put off by a lack of empathy from health professionals
and a fear of harming or hurting their child (7). Difficulty in accessing
the health system because of social and living condition constraints
has also been reported as negatively influencing vaccination rates (10).
Our study followed recognised qualitative methods (11,13). Participants
came from groups selected because of their interest in vaccine issues.
Although such probabilistic sampling methodology does not seek to be
representative, we believe that our findings do represent the widespread
views of parents and health professionals in the region because participants
came from diverse geographic, socio-economic and professional backgrounds
in the SHB. Additionally, the themes identified were common to all groups.
Vaccination is a voluntary choice in Ireland, but as highlighted in
this study, concerns about vaccines and frustrations with available
information are widespread among parents. Our findings are unlikely
to be local findings, and those feelings of fear, uncertainty and mistrust
deeply rooted among parents (and the wider community) need to be addressed
at the national level.
The variation in knowledge and attitude to vaccinations among health
professionals is of concern. Health professionals' ambivalence about
vaccinations (14), inability or unwillingness to answer parents' questions
or lack of empathy with parents and children have all been reported
to have negative impacts on vaccination uptake (7).
In an effort to address the information needs of both parents and health
professionals a number of activities took place: the findings from this
study were presented at local and national meetings; a full report was
sent to all participating groups (GP trainers, parents, practice nurse,
midwives, public health nurses); a report summary was sent to all regional
GPs; a summary report was published in Forum, the Journal of the Irish
College of General Practitioners (15); and senior immunisation public
health nurses increased information dissemination and communication
activities to other public health nurses, GPs, practice nurses, midwives
and community groups.
In response to the specific uncertainty expressed about MMR vaccine,
a special information pack was prepared immediately after the study
(16) using a similar model that had been developed in Scotland (17)
and Wales (18). This pack provided information in easily understandable
language for parents about the relevant diseases (measles, mumps, rubella),
the vaccine, and answers to commonly raised questions. Additional information
for health professionals was also provided in the pack to assist them
in responding to more specific questions. The colourful, easy to use
pack, contained in one attractive folder, was sent to each GP in the
region and was available on health boards websites throughout the county.
This pack was welcomed by both primary care providers and health boards.
It provided a national attempt to provide clear, understandable and
standard information to the community.
Recommendations
A number of key areas to restore trust and increase knowledge and acceptance
of vaccines were identified:
- disseminate information that is accessible, balanced, and evidence-based.
Parents will differ in how much information they want, but it is vital
that these varied needs are adequately met.
- provide information in appropriate formats. Innovative communication
methods should be encouraged (videos in health care settings, television,
newspapers and radio, information exchange occurring in informal settings
(e.g. mother and toddler groups).
- authoritative and respected authorities need to correct misinformation
rapidly. Automated systems, including emails, faxes and text messages
on mobile phones will need to be developed to ensure a timely response
system.
- restore confidence in the vaccination programme needs a commitment
of all individuals in the health services to high quality, efficient,
transparent and accountable services, focussing on the patient as an
individual.
Addressing all these issues is not easy but can be achieved with commitment,
coordinated effort and appropriate resources. The challenge is to make
it happen.
Remerciements / Acknowledgements
Nos remerciements sincères aux parents et aux professionnels
de santé qui ont contribué à cette étude.
/ Sincere thanks to the many parents and health professionals who participated
in this study.
Notes
Office central des statistiques / Central Statistics Office (CSO).
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