MMR uptake in Somerset following the 2009 national catch-up campaign : factors affecting parents' decisions to accept or decline immunisation

Introduction and Background: Measles, mumps and rubella (MMR) are infectious diseases, primarily of childhood, which cause significant mortality and morbidity globally. These infections are, however, vaccine preventable and there is potential for them to be eradicated worldwide through the strategic use of organised population immunisation programmes. Following the introduction of the MMR vaccination in the UK in 1988, uptake was initially good and a high level of population vaccination coverage was achieved. This was sustained until 1998 when a study by Dr Wakefield and colleagues was published in the Lancet suggesting the theoretical possibility of an association between MMR and Autism/bowel disease. Intense media coverage followed, uptake of MMR vaccine fell to less than 80% in Somerset, and community outbreaks of measles, which had almost been eliminated in the UK, began to reappear. The Wakefield study was subsequently discredited and was eventually retracted by the Lancet in 2010. In August 2008 the Chief Medical Officer announced a national MMR catch-up campaign, targeting all children between the age of 13 months and 18 years who had either not been vaccinated against measles, mumps and rubella, or had only partial immunisation. These children were invited again for vaccination and the campaign was completed in January 2009. This study was undertaken to explore, in depth, the quantitative data available in respect of the uptake of MMR at the time of the 2009 campaign, and also to provide new qualitative data in relation to the attitudes, beliefs and experience of MMR and immunisation services of parents who continued to decline MMR for their children after the 2009 campaign, in order to identify factors which affected parental decision-making, add to the wider knowledge base, and to use this knowledge to improve the future development of immunisation services in Somerset. Methods: The overall objective of the study was to investigate a number of social, demographic and geographic characteristics of parents and children associated with MMR uptake, to compare these characteristics within and between defined sub-sets of the Somerset population, and to explore the basis on which parents in Somerset make decisions in relation to MMR immunisation. The study design adopted was a ‘mixed methods’ approach comprising of a cross-sectional design with three sequential phases - an exploration of baseline epidemiological data; a survey conducted with parents of children who remained unimmunised after 2009; and finally, semi-structured interviews with a sub-set of these parents. Results: The key findings from the study are: Parents who decline MMR for their children are not a homogenous group, but consist of a number of sub-groups each of which have different motives, decision pathways and predicted outcomes in relation to potential to change their mind and accept MMR There are differences in geographic distribution between the two age groups investigated Whilst the ‘Wakefield’ study did, and still does have, an impact, it is not the only or most important factor in their continuing decision-making. There is evidence that health professionals have a key role in addressing parental concerns in respect of immunisation. GP practice was the most significant factor associated with uptake in the Phase 1 study, and this was further confirmed in interviews with parents. Parents make decisions through engagement, through communicating and relating to others and this offers a potential mechanism for health professionals to influence decisions through open engagement with parents. Discussion and Conclusions: Three parent sub-groups were identified (Single Vaccines; Medical Comorbidities and Natural Health). These sub-groups were further investigated and factors associated with the decision-making pathways of each group were identified. This resulted in the development of the ‘MMR Parent Engagement Framework’ as a tool for use by professionals in planning their interactions with parents to improve and encourage more open dialogue in order to positively influence parental decision-making in relation to accepting MMR or other vaccinations. From a commissioning perspective, embedding frameworks such as this in service specifications offers a more cost-effective approach to improving immunisation uptake than funding large, poorly targeted catch-up campaigns. It is therefore recommended that further research is undertaken to provide evidence of the effectiveness of the approach in practice, and to inform future commissioning decisions. Additional recommendations to improve the effectiveness and delivery of immunisation services are also made in respect of GP Practice specific factors, independent schools, ethnic minority communities, vaccine overload, media, and data validation. The study has already directly influenced changes in current practice at both a local and a national level.