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Immunisation

Messages to health professionals

In the United Kingdom, childhood immunisation has become a controversial issue, which is an ongoing challenge for health professionals. When claims were made by Wakefield et al', of a link between MMR, inflammatory bowel disease and autism, and parents' concerns were being fuelled by sensational reporting in the media, the Department of Health took the approach to firmly deny that immunisations were attached to such risks. Some parents were not convinced and some lost trust in the information given by health professionals about immunisations. 

However, health professionals do now have a huge body of good research evidence available to them, which indicates the effectiveness and safety of the vaccines.

Here, the parents we interviewed talk about what helped and what didn't help them when discussing their child's immunisations with a health professional. 

The overwhelming majority of parents believe in immunisation for their children. We have however included here the views of a few parents who do not believe immunisation is right for their own child based on their personal beliefs. Their views represent a small proportion of the population.

Building trust with parents

  • When health professionals acknowledged and explained all the risks involved with immunisations, parents felt more able to trust them, than when concerns about potential risks were dismissed. 
  • When parents felt that doctors were giving their own professional opinion based on an assessment of the child's personal medical history, rather than just giving out a government line, they were more likely to trust what health professionals were saying. 
  • When health professionals didn't just assume that their child would be immunised but talked about the choices parents had, parents were more likely to take on board the advice that was being given.
  • Parents would like health professionals to be open and honest about the reasons behind some of the advice they give. 
  • Parents want to feel partners in informed decision-making and not to feel coerced in to immunising their children.
  • Parents would like the vaccine product insert sheets detailing the components of the vaccine, when the manufacturer states it shouldn't be given and the side effects associated with their products. Information on adverse vaccine events is not collected reliably through the 'yellow card' scheme and adverse vaccine events are under reported. 
 

Acknowledge and explain all the risks involved with immunisations, rather than dismiss parent's...

Acknowledge and explain all the risks involved with immunisations, rather than dismiss parent's...

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Father' I think that they have to empathise with the difficulty of making a decision under the kind of glare of media speculation. Suffice to say I think they probably presented it as a kind of considered decision to be made rather than an inevitability. I think if they'd presented it as an inevitability I think people who maybe think they're informed and are worried will then recoil from that. So I think they should present it as something that is to do with, you know, it's a considered decision rather than a kind of inevitability. And I think probably it's probably best if they relate their own sense of dilemma and research and some of that uncertainty in it all.

I think if a doctor presents it as a certainty and is blas' and brash and confident, over-confident, that would certainly make me recoil and think twice. Because it would make me feel they're selling it to me rather than giving me the facts, which I'm sure the facts can be disputed otherwise they wouldn't have been a scare. I'm sure the facts are that actually you can't say categorically that it doesn't cause autism. So if someone were to tell me, maybe statistically this and this and this, but if they were to be very persuasive and very categorical that would make me recoil from any clarity about what I actually was going to do.

 

It is better to give a professional opinion and explain on what evidence the opinion has been...

It is better to give a professional opinion and explain on what evidence the opinion has been...

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I think where you, wherever you felt they were talking from their own opinion rather than from the government line you, you were far more likely to trust what they were saying. If you felt they were regurgitating something they didn't believe, and you can kind of generally tell when people are sort of spinning out a, a line. Whereas when people were fairly adamant that it was, you know, kind of not worthy of, paying too much attention to, I was much more reassured by that. Not to encourage people just to lie about it, but it's, you did genuinely kind of want to know what they would do with their own children rather than what the government line was. 

And although I know that it's very difficult in a, in a professional thing, there's a limit to how much you're allowed to say, as a parent all you want to know is that your child's going to be all right. And so it, it's not reassuring to know what the government line is. It is reassuring to know that ultimately your doctor as a professional feels that your child's going, on an overwhelming basis of evidence, is going to be fine at the end of it. And it may be that they're the same thing, but you want to have it from their personal opinion rather than from a kind of government line, that someone is going to take responsibility at the end of the day for what happens. And I think, not in that you'd want to sue them or, just that your child's, you know, basically all you want to know is that your child is going to be okay. So anything that reassures you about that is probably the best way forward.

 

Be honest about the reasons behind some of the advice given.

Be honest about the reasons behind some of the advice given.

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I was told, for example, that I was putting my daughter at great risk if I didn't give her the first set of immunisations because, given that the, we were just at the time when they are, this vaccine was being phased out and replaced by the other one, within the next 10 days, I asked, well could we wait and have the new one. Because my view, well our view was that if it, if this vaccine was being removed it, there had to be reasons for that. 

So I said, 'Well, I'd rather wait for the next 10 days.' And the, and I was told that it was not possible and I was told that the reason why it was not possible was because I was putting my daughter at great risk of catching diphtheria within the next 10 days if she didn't have the vaccine. Which I think is, is not right. Because of course that's not the reason why the GP wanted her to have the vaccine. The reason was that, it was changing in 10 days and until then he had to vaccinate a number of people and he just wanted to get it done. And so I, this made me feel a little bit ill at ease and so it was not right, to wave the, the risk of disease and to try to convince me that I was being irresponsible and putting her at risk.

They wouldn't like, they wouldn't like to be told half of the, half of the truth when they have to decide what they want to do with their children. So I think it's just the same for everybody.

Respect parents' worries and listen to their concerns 

  • Take time to answer questions or discuss concerns and help parents to be well informed. Provide copies of the vaccine manufacturers' product insert sheets and discuss the contraindications in relation to the child's personal and family medical history. Respect parents' concerns and be open to their suggestions, volunteer information and invite parents to ask questions. 
  • Don't treat parents as if they are stupid.
  • Don't treat the MMR decision in a flippant way. Payments have been awarded by the Government's Vaccine Damage Payment Unit for children who have been affected by vaccines.
  • Don't assume that at the six-week check, parents will be having the immunisations. This may be the first time the subject of immunisation has been raised. Some parents will need time to consider the issues in relation to their child's health and medical history. They will need comprehensive information and all parents should have access to a trained health professional to talk to about the risks of catching the diseases and about the benefits and potential risks of immunisation for their own child, and the population in general.  
 

Find out what parents' concerns are and address them.

Find out what parents' concerns are and address them.

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Well certainly the nurse that I've spoken, that I spoke to was very informed and that always helps make a decision is, is having trust in the person that you're talking to that they actually do know what they're talking about, there's nothing worse than talking to someone and you think “This person actually hasn't got a clue,” and they don't instil any confidence in you whatsoever. So she may have been talking complete rubbish but she sounded like she knew what she was talking about, so I believed her. 

And I think on my six week check-up when I spoke to the doctor then about them and she sort of said you know in your little red book it asks about immunisation and she asked if I had any, you know she raised the subject, was I thinking of having him done, did I have any questions about them and I think just the fact that she was very open and you know inviting questions. And I didn't have many because I'd always thought that I would have it done, it was before the onset. But I think doctors can, you know they raise, if they raise the issue and ask if there's any questions, anything that they're unsure about at that stage rather than the parent at the six week check, rather than the parent just getting this form through. I think that was explained to me as well, that was explained to me by either the health visitor or the doctor that, you know how it worked because I didn't know whether I had to make all these appointments myself or whatever. 

So it was explained that I would get an appointment through and then you just turn up or you cancel it or, and re-book, whenever. So I think that helped that, actually having the process explained that you didn't have to do anything. I think as long as they talk to you like an adult and don't “Oh you just must have them done,” as long as they sit down and actually find out what your concerns are rather than dismissing you like you're silly, then I think that helps a lot of people.

 

Recognise that the MMR decision is a difficult one for many parents.

Recognise that the MMR decision is a difficult one for many parents.

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They said, after they'd weighed her they said, 'She is due for her MMR'. And because I came at the end of the session the nurse was just kind of lingering around basically. And I said, 'Yes, but we're choosing to do the individual'. And then the nurse heard and she walked in and she said, she said, 'Oh, but, no, don't worry. Just the one jab, it's just quick'. 'No'. And I thought, 'I'm not going to get into this with her because I don't need to'. I said, 'No, no thanks, no we're fine'. 'But, now, look, just a, I've just got it here. Quick, come on, just come in. It'll only take a second. She'll be fine'. And I'm like, 'No, I'm really, no, we're fine'. She said, 'Oh, come on' and then she started laughing. And I thought to myself, 'It isn't just a quick thing'. And she just did not understand. It's a decision. It's not about just something quick, kind of, 'Oh, look, I've got five minutes, quick, we can get it done'. And I thought, 'That's really not the right attitude to have, and definitely not to press someone'. 

 

Don't assume that at the six week check, parents will be having the immunisation.

Don't assume that at the six week check, parents will be having the immunisation.

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And again I find it extremely inappropriate that they make the appointment so that the assumption is you will have the immunisations without ever having seen a doctor. You know, you've only had your baby for six weeks, it's all very new. Nobody, you don't receive any support at all. I'm involved in the maternity services here, and so there is very, very little support, let's say no support for new mums. Midwives are completely overworked. There's not enough health visitors. And then the health visitor, when she did come was completely overwhelmed with paperwork, so I really didn't have the time to speak to her about anything. So if I wouldn't have had any friends in the medical profession I wouldn't have had any information whatsoever, unless I sit down and read on the Internet, which I think is completely inappropriate because it's uncensored, well, it's unchecked.

  • Listening to parents and being able to answer their concerns with comprehensive information can influence the decisions parents make about their child's immunisations.
 

Listen carefully to parents' concerns so that you can answer their questions.

Listen carefully to parents' concerns so that you can answer their questions.

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The good way is listening properly to what you've got to say and to what you're asking. The impression I got when I was first given advice at the first hospital, was the fact that the registrar had, had a quick word with the consultant before, looked at my note. The consultant said, 'Well when you see the patient, well, patient's mother's, say this' and say that's what she did, so she couldn't' I mean, maybe she's still training, so she couldn't answer any more questions. Then she went and got the consultant and he wasn't listening to me either.

And I think, that when I spoke to the paediatrician immunologist, he sat quietly, he listened to everything I said and then he gave me his response to my concerns and I think that was the big difference.

It's very easy to' especially if you've come across things before, just to, and you're busy, to feel impatient and think, yes, yes, yes, I know, I don't want to know all about the details' this is what your question is. But actually if you listen to someone properly, then it might not be their question and then you might be able to reassure them about things that you didn't know that (they) would ask you. So I think it was listening properly and answering your question, rather than just telling someone what you think they should be asking you, because that then' yeah because it's almost like you had a prepared answer that you' it was almost like the consultant was getting frustrated with me for not asking the question, he wanted to answer [laughs]. And I've seen that in lawyers, a lot as well, where they say, 'No, you, what you' you don't want to ask me that question. You want to ask me another question.' And I know the reason they say that is because they don't know the answer to the question, that you have actually got. So that's what I would say.

 

Her questions and concerns were not answered by the health professionals she talked to which...

Her questions and concerns were not answered by the health professionals she talked to which...

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I think again as in anything, particularly in parenting, you're always doubting yourself anyway. And, and I think just for somebody to have had a listening ear really and just to have had more time, just to have said, 'Well as we're discussing now, you know, 'What, exactly what's concerning you? Why are you sceptical? What, what has brought this to your mind?' You know, 'What...?' And actually listen and just say, 'Yes, I understand where you're coming from'. And then perhaps being able to give facts and figures and information from their point of view.

  • When parents bring their child to see a health professional with concerns that their child may have had a reaction to MMR, be sympathetic, note the symptoms, study the vaccine manufacturers' product sheets or the Green Book and report the suspected adverse event for investigation, if appropriate. 
 

Would have preferred the doctor not to have dismissed out of hand his concern that his daughter...

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We also had a really bad time with doctors as soon as we mentioned the three letters MMR it was almost like a switch flicked and either they got incredibly defensive or we were blinded with apparent science. And I said, 'Look, please, you know we're not interested in scientific evidence. What we're saying is that there are three possibilities, and you've discounted the trauma,, this leaves the chicken pox or the MMR as possible culprits.' And at every turn we were stonewalled. 

There was one day when I went in and a doctor was talking to my wife who was in tears and was telling her that it was none of these things and that they were going to look for a sort of mystery virus. And I said, 'Well why are you looking for a mystery virus when you have a possibility that three cultivated viruses that were injected into her may well be responsible?' And he said that they weren't even going to consider it. And I said, 'Well surely that isn't logical?' I didn't question his scientific or medical knowledge, I said, 'From the point of view of logic surely these should simply be investigated.'

And in fact he and I had a stand up row, on the ward, in front of all the other parents who got upset of course. I tried to keep calm and as far as I know I was calm, at one stage he turned to my wife and said, 'You're getting very emotional about this.' And my wife had to walk away because what she of course later said she wanted to say was, 'Well, you know, if you can't get emotional about your child having what appears to be some kind of brain damage, what can you get emotional about?' And I said to the doctor, having my wits about me a little, 'Do you have children yourself?' and he said, 'No' I said, 'Well I'm sorry but you can't possibly know what it's like to have a child who appears to be brain damaged who is apparently totally healthy two weeks or so ago.

I would have just liked the doctor to have said something like, 'We understand your concern.' He may even have said at the time, 'personally I don't think that that's responsible, but of course we'll look into it.' And if he'd said just that I would have been reassured. He didn't listen and in fact he lectured me and not only that he started to argue with me.

 

She would have liked the health visitor to take her concerns about possible reactions to MMR...

She would have liked the health visitor to take her concerns about possible reactions to MMR...

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I think I'd have liked her to have taken notice of what I'd said. I explained to her, I said, 'She had a really, really nasty reaction, her arms swelled up and she was on anti-histamines, antibiotics and everything, I'm just concerned that he's going to get it.' And she was just very dismissive, there were no, I think I would have liked to have said, 'Oh right, well I'll just go to speak to the doctor about it, maybe we can pull [my daughter's] file out and see what, you know, how she reacted and everything.' Maybe the GP should have done it, or he should have said, 'you know,' Or maybe there's a test they could have done, I just, I'd have liked them to have been more concerned because I were, you know. I mean, I still let them go ahead with it, I probably shouldn't, shouldn't have, thinking about it, I should have said, 'No, I want to speak to the GP about it.'  

Give reassurance and try to understand what it's like from a parent's perspective

  • Health professionals should be prepared to answer questions from parents about the immunisation decisions they made for their own children but should ensure that they have also balanced the risks for the individual child in front of them.
 

Remember the personal approach when talking to parents.

Remember the personal approach when talking to parents.

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It is very important because they should respect your worries, they should be there, they should listen and they should help you out of these worries. I ended up crying there because I actually felt like, 'They really don't care' in a way. I mean it's not  the right way to say it but they really don't, how do you say it in English? they don't want to come down to your level and understand your feelings in a way. They only have the medical information that is actually given by probably the government or the health authorities and that is it. There's no personal approach at all. I think that the personal approach is missing, because a doctor is more than just a conveyor of information from health authorities, especially a GP, because he sees you frequently, he sees your child frequently. I think the personal touch is missing, really treating you in a way that you are an individual and not just, 'Okay, I'm conveying the message I have from the health authorities and that's it. And I'm not interested in anything else you have to say'. 

 

Put yourself in the frame of mind of a parent.

Put yourself in the frame of mind of a parent.

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Also I am inclined to believe that junior doctors, they tend to be in their twenties, you know, many of them do not have families yet. So it's more difficult for them to perhaps, to put themselves into the frame, the mind frame of a parent. So it's very easy for you as a doctor to just say, 'Well, you know, have the vaccine. That's it. Because I say so'. While as a parent you have so many worries about your child. Just the idea of putting a needle inside them is painful for you. It is heart-rending. And so you won't accept anything like that unless you are totally convinced that it is absolutely necessary and good for your child. So I think there is more need of empathy and volunteering the information even without it being asked, to try and make parents feel more comfortable about it and more open about it.

 

It helped her to make a decision when the health professional talked to her from one mother to...

It helped her to make a decision when the health professional talked to her from one mother to...

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And she was just able to tell me exactly what the current sort of comment was on it and stuff and also it wasn't just her giving me the facts, she was also talking to me as a mother as well. She's got children of her own and she was talking to me from that perspective. So I kind of felt, unlike with our local doctor who other people were commenting, 'Oh they will just give you the party line,' I felt as if she was telling me exactly what all the facts were as well as the fact she was a mother and she was also being honest with me about how she felt about it.

Be well informed so that you can give parents the information they need

  • Well informed health professionals, who discussed issues with confidence and were able to provide reassurance helped to instil trust in parents. 
  • Some parents found it more helpful to talk to a trained health professional than being given written information. But not all parents want information and the opportunity to discuss immunisations with a health professional.
 

She was more reassured when it was obvious that a health professional had reviewed the evidence...

She was more reassured when it was obvious that a health professional had reviewed the evidence...

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I was more reassured as well when people had clearly looked at the evidence. Where people were able to say, 'Look, this is...'. I mean I, as I said before, 'This is what the research was. This is what is was based on. This is the kind of outcome of it'. And where they clearly themselves had considered what the issues were rather than just, 'It's fine. Don't worry about it. It's not worth worrying about'. Where, it's just not reassuring at all because you're not even aware of whether they really know what those issues are. It was much, yes, much more reassuring. You felt that they too had considered as a professional and weighed up on a balance of judgement whether it was likely to be detrimental or not.

The immunisation clinic

  • A child friendly clinic, held at convenient times, with friendly, well informed trained health professionals can make a difference to parents' decisions to return for future immunisations.
 

The environment in which immunisations are given and the timing of clinics can affect parent's...

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Well, I think that a trainee doctor, who's setting up their own surgery, this is not only for immunisations but for anything, it's very worthwhile to think about what their waiting room is like. Because if you've got a waiting room that's got no toys in whatsoever, children get very irritable. And also if they can make their immunisation clinics at a time that's suitable for mothers. I mean to make it half past two to half past three in the afternoon, I think because in the general world, people don't have so many children, so it could be that the person, child that they're immunising is their only child or that their other child is, there's a big gap. But with the Orthodox Jewish community, some people have a child like every eighteen months. And so when they're taking their child to be immunised, they could easily have a child in nursery as well that has to be picked up at half past three. So a doctor needs to think about their immunisation clinic times, what the waiting area is like, and make sure they have enough immunisations for that clinic. Someone shouldn't have to go there and then find they haven't got the immunisation available. 

 

Last reviewed October 2015.
Last updated July 2013

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