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Changing attitudes to childhood immunisation in English parents
Vaccine 35 (2017) 2979–2985
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Changing attitudes to childhood immunisation in English parents Helen Campbell a,⇑, Angela Edwards b, Louise Letley b, Helen Bedford c, Mary Ramsay a, Joanne Yarwood b a
Immunisation, Hepatitis & Blood Safety Department, National Infection Service, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom Immunisation, Hepatitis & Blood Safety Dept., National Infection Service, Public Health England, Wellington House, 133-155 Waterloo Road, London SE1 8UG, United Kingdom c UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom b
a r t i c l e
i n f o
Article history: Received 8 November 2016 Received in revised form 27 March 2017 Accepted 30 March 2017 Available online 23 April 2017 Keywords: Immunisation Childhood Acceptability Confidence Vaccination Trust
a b s t r a c t Objectives: We undertook a national survey of parental attitudes to childhood vaccinations and compared results with those in earlier comparable surveys covering a 10 year period. Methods: We randomly selected 275 nationally representative sampling locations in England. Interviewers identified eligible primary care givers (referred to as parents) of children aged from 2 months to <5 years and conducted home-based interviews between January and April 2015. We aimed to recruit 1000 parents of children aged 0–2 years and 1000 of children aged 3–4 years. The questionnaire covered all aspects of the immunisation process, vaccines administered in pregnancy and from infancy to pre-school with a maximum of 86 mixed questions. Results: Interviews were completed with 1792 parents of whom 1130 had children aged 0–2 years and 999 had children aged 3–4 years; 337 had children of both ages. The findings showed that confidence in and acceptance of the vaccination programme was high. Only 2% of parents reported refusing vaccination whilst 90% reported vaccinating their children automatically when due. Almost all parents (97%) had access to the internet and 34% consulted web-based resources for information on vaccination. Parents who used chat rooms or discussion forums for this purpose were significantly more likely to say they had seen something that would make them doubt having their child(ren) immunised (31% compared to 8% amongst all parents). Health professionals and the NHS were seen as the most trusted source of advice on immunisation (90% agreed/strongly agreed with each). Very few parents did not trust these sources (4% and 3% disagreed, respectively). Conclusions: Health professionals remain extremely important in communicating information about vaccination and are highly trusted by parents; a trust that has increased in recent years. Despite most parents seeking information on the Internet, trust in and advice from health care professionals appeared to be key factors influencing parental decisions. Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
1. Introduction The routine childhood immunisation programme in England aims to give every child the opportunity to be protected against vaccine preventable diseases. Immunisation is voluntary and free of charge for all children for every vaccine included in the routine programme. The programme has high uptake rates, with only a very small minority of parents refusing vaccination for their child. As a result, targeted diseases have been markedly reduced with many, including diphtheria, tetanus, rubella, Hib and meningococcal group C disease, now rare and polio eliminated. Maintaining high coverage rates can be challenging in the absence of disease
⇑ Corresponding author. E-mail address: [email protected] (H. Campbell). http://dx.doi.org/10.1016/j.vaccine.2017.03.089 0264-410X/Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
[1] but uptake in England currently exceeds 95% for most vaccines given in infancy and 90% for pre-school boosters offered at around the age of three years four months [2]. National vaccination programmes in England are supported by a long-running series of cross-sectional surveys exploring parental attitudes to childhood immunisation [3]. Even with high uptake parental requirements may change, particularly with revised programmes or new vaccines. To ensure parents’ needs continue to be met it is important to understand their opinion on vaccines and vaccine preventable diseases, their vaccination experiences and what affects their vaccination decisions. This paper presents the views of parents with children under five years of age in the 2015 survey. Differences over the previous 10 surveys running from November 2001 to March 2010 will also be examined with a particular focus on any changes since the previous survey in 2010.
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2. Methods
Over time data were based on parents of 0–2 s to ensure comparability.
2.1. 2015 Survey For a nationally representative sample, 275 sampling locations in England were randomly selected. The sampling points were based on two combined 2001 Census Output Areas each containing about 125 households [4]. Sampling was stratified by region and Index of Multiple Deprivation quintile. Census output areas were selected with probability proportional to population size. Interviewers were given quotas for each sampling point by age of child and parental working status. Interviewers identified eligible primary care givers1 (referred to as parent throughout) of children aged from 2 months to <5 years who were willing to participate in a study about the health of young children using door-to-door market research methods. The target was to conduct 1000 interviews among parents of 0–2 year olds and 1000 interviews among parents of 3–4 year olds. Interviewers conducted face-to-face interviews between 19/01/15 and 1/4/15 using Computer Assisted Personal Interviewing. The questionnaire covered all aspects of the immunisation process, vaccines administered in pregnancy and from infancy to pre-school with a maximum of 86 mixed open and closed-ended questions. Some required ‘spontaneous’ or ‘prompted’ answers: the respondent was first asked to give an answer based on spontaneous recall; they then selected from listed possible responses. Responses to open-ended questions were recorded verbatim and ‘coded’ into categories of like responses. To ensure data were representative of parents of children aged 0–4 in England they were weighted by respondent/child age and by region. Targets for age of parent by age of child were taken from the December 2014 Labour Force Survey [5], and region (of households with dependent children aged 0–4) from the 2011 Census [6]. Parents were categorised as ABC1or C2DE social grade according to the occupation of the chief income earner [7]. Data were managed using SPSS (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp). Differences were tested for statistical significance in Merlin (version 9.6.51) using a two-tailed T-test on column proportions. Where a difference was significant at the 95% level, this is indicated. 2.2. Changes in survey methodology over time Prior to March 2003, interviews were carried out with mothers only. Since then primary care givers, whether men or women have been interviewed. Before 2010, surveys included parents of children aged 0–2 years only. From 2010, parents of children aged 3– 4 years were also included, covering the childhood immunisation programme to pre-school. It was at this time that the sample size was increased from 1000 interviews to a total of 2000; with 1000 among parents of 0–2 year olds and 1000 among parents of 3– 4 year olds. The surveys were undertaken at least annually until 2010 and recommenced in 2015. Previously, some questions were divided by parents of children aged 0–2 years old and of children aged 3–4 years old. In 2015, to better reflect the timing of pre-school boosters (offered 3 years after completing the primary infant course, scheduled at 8, 12 and 16 weeks of age) questions were divided according to the age of the child into those for parents of children aged 0–3 years 3 months old (denoted as ‘0y-3y3m’) and parents of children aged 3 years 4 months to 4 years 11 months old (denoted as ‘3y4m-4y’). 1 A ‘primary care giver’ was defined as the person responsible for most decisions about the child’s health care.
3. Results Interviews were completed with 1792 parents of whom 1130 had children aged 0–2 years and 999 had children aged 3–4 years; 337 had children of both ages. Although the methods do not allow ascertainment of the number of eligible households that refused to participate, weighting by respondent age, child age and region was designed to ensure the representativeness of parents of children under five years of age in England (Table 1). 3.1. Immunisation and disease awareness Fifty-one percent (N = 909/1792) of parents recalled seeing, hearing or reading information relating to childhood immunisations in the last year, declining from a 91% peak in 2001 (Fig. 1). Of these, 909 parents 12% (N = 109) spontaneously recalled information that might make them doubt getting their child immunised or persuaded them not to immunise. This was part of an overall decrease in exposure and/or recollection of such information (Fig. 1). Twenty percent (N = 182/909) said the information they recalled concerned the importance of getting children immunised. Doctors/nurses (17%), leaflets (10%), TV in a pharmacy or GP surgery (9%), Internet (6%) were the most common information sources. Mention of most sources fell significantly compared to 2010, other than doctors/nurses. This was consistent with the reduction in national immunisation publicity campaigns using paid for TV and press. Seeking information via the Internet increased from 4% to 6%. When prompted, 12% of all parents (N = 149/1792) recalled seeing, hearing or reading something that made them doubt getting their child(ren) vaccinated. This most often related to nonspecific side effects (23%, N = 34/149), danger of autism/ Crohn’s or ADHD (attention deficit hyperactivity disorder) (16%, N = 24/149) or MMR (measles, mumps and rubella) vaccine (7%, N = 10/149). Thirty-four percent of these parents said that adverse information related specifically to MMR vaccine (N = 51/149) and 26% to flu vaccine (N = 39/149).These parents were most likely to have seen this information on the Internet (32%, N = 48/149) or through speaking to friends, family or other parents (26%, N = 39/149). The diseases perceived to be most serious, rated as ‘very serious’ by the most parents, were Meningitis (82%), Septicaemia (78%), Pneumonia (71%) and Polio (68%). An ear infection was seen as the least serious, rated as ‘very serious’ by 14% of all parents, followed by chickenpox (17%), diarrhoea and vomiting (18%), flu (22%) and rotavirus (25%). 3.2. Decision-making process In 2015, 90% of parents (N = 1613/1792) reported automatically having all their child(ren)’s immunisations done when they were due, a significant increase from 72% of parents (N = 1246/1730) in 2010 (Fig. 2). Mothers were significantly more likely to have refused or delayed an immunisation than fathers (11% compared to 7%). Parents living in the South were also significantly more likely to have refused or delayed (15%) compared to those in the North or the Midlands (both 7%). Seven percent (N = 125/1792) of parents postponed immunisations offered to their child(ren), significantly fewer than in 2010 (19%); of these, 5% immunised later and 2% intended to immunise later (Fig. 2). Forty-two percent of those delaying said that this was
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H. Campbell et al. / Vaccine 35 (2017) 2979–2985 Table 1 The population structure of the unweighted sample achieved by the survey and the adjusted totals by weight/target according to population profiles in England.
a
Category
Characteristic
Unweighted bases
% Unweighted
Target/weighted Bases
% Target/weighted
Gender
Female Male
1468 323
82 18
1460 331
82 18
Age
16–24 25–34 35+
234 930 618
13 52 35
241 926 615
14 52 35
Social grade
ABC1 C2DE
686 1060
39 61
694 1054
40 60
Age of children
Any aged 0y2m to 2ya Any aged 3-4ya
1130 999
63 56
1187 884
66 49
First time primary care giver
1 child onlya More than 1 child (any age)a More than 1 child and all under 5ya More than 1 child and oldest 5+ya
744 1048 354 694
42 58 20 39
791 1001 324 677
44 56 18 38
Ethnicity
White including White other BME
1426 143 362
80
79
20
1413 150 376
21
Working status
Working Not working
913 872
51 49
917 869
51 49
Marital status
With partner Single/Widowed/Divorced/Separated
1387 396
78 22
1387 397
78 22
Disability
Yes No
50 1738
3 97
49 1739
3 97
Region
East Midlands East of England London North East North West South East South West West Midlands Yorkshire and The Humber
143 179 269 108 215 358 143 215 143
8 10 15 6 12 20 8 12 8
142 195 321 88 231 285 159 195 177
8 11 18 5 13 16 9 11 10
Total
1792
1792
These proportions are presented as % of all parents whilst others are presented as % of those providing this information.
Fig. 1. Whether seen, heard or read anything about childhood immunisation recently (among parents of 0–2 s only) and whether this might dissuade you from immunising your child.
due to their child being ill (which equates to 3% of all parents). This was significantly higher among postponing parents aged 25–34 (50%) compared to parents aged 35+ (28%). Eighteen percent of these 125 parents who had postponed immunisations missed the appointment (equivalent to 1.3% of all respondents) and 7% had
concerns about side effects or consequences (equivalent to 0.5% of respondents). Only 2% of parents (N = 43/1792) refused an immunisation offered to their child(ren), compared to 9% in 2010 (Fig. 2). The 43 parents who refused immunisations provided different reasons
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72%
28%
Fig. 2. Whether parents said they had ever refused or delayed any immunisations.
which included; having an objection to the vaccine (N = 9, 21%), concern over reactions and illness after immunisation (N = 9, 20%), safety of immunisations (N = 6, 13%) and their child’s health at the time (N = 5, 12%). Overall 2% of parents said they refused flu vaccine and 1% refused MMR vaccine. Of all 0y-3y3 m parents, 8% (N = 102/1313) weighed up the pros and cons before immunising (Fig. 3, showing parents of 0–2 s), the main consideration was the danger/risk of side effects, mentioned by 47% of these parents (Fig. 4) and by significantly more first time (57%) than experienced parents (41%). Of this small number of parents fewer mentioned MMR in 2015 (65% in 2010 to 50%, N = 41), continuing the recent decline in concerns around MMR vaccine. Only 9% (N = 72) of parents of older children reported weighing up the pros and cons and the proportion of these parents with concerns about MMR vaccine also declined (91% to 54%, N = 39).
3.3. Immunisations that parents would not allow a future child to have Eleven percent (N = 202/1792) of parents said there was a vaccine they would not allow a future child to have, representing a significant decline from 18% of parents in 2010 (Fig. 4). By social grade, ABC1s were significantly more likely to say they would refuse an immunisation for another child in the future (13%) compared to C2DEs (10%). Among the 202 parents, flu vaccine (20%) and MMR vaccine (16%) were those most commonly cited. 3.4. Interactions with health professionals Health professionals and the NHS were seen as the most trusted source of advice on immunisation (90% agreed/strongly agreed with each). Very few parents did not trust these sources (4% and 3% disagreed, respectively). High level trust (strongly agree only)
Fig. 3. Whether automatically had child immunised or weighed up pros and cons (among parents of 0–2 s).
H. Campbell et al. / Vaccine 35 (2017) 2979–2985
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Fig. 4. Issues taken into account when weighing up the pros and cons of immunisation.
Fig. 5. Trust in sources of advice about immunisation over time (among parents of 0–2 s).
in all sources had increased significantly since 2010 (Fig. 5) with the least trusted being the media. Whilst trust in the government was not high (only 33% of parents strongly trusted advice from the government on immunisations) this is also an improvement since 2010. A lower level of trust in the government may not impact on attitudes to the national immunisation programme in England as the NHS and its staff, where trust is consistently strong, are most directly linked with communications and delivery of the programme.
Parents who trusted the advice (strongly agree) given by health professionals were significantly more likely to have had all immunisations done when they were due (93% compared to 85%), whereas less trusting parents were significantly more likely to refuse or postpone (15% compared to 7%). Of 72% of parents who discussed immunisation with health professionals, 47% said they felt more confident about immunising their child and only 3% said they felt less confident about immunising their child after the discussion.
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Twenty-four percent of parents said they would have liked more information about immunisation including: side effects (8%), more/general information (7%), purpose of the immunisation (2%) and vaccine ingredients (2%). This was a significant decline since 2010 when 39% said they would have liked more information. 3.5. The internet and social networks Eighty-four percent of parents used the Internet daily compared to 62% in 2010 and 9% used the internet several times per week; only 3% never used the internet. Sixty-six percent of parents had heard of the NHS Choices website and 45% of all parents had visited it. Of 626 parents (34%) who used the internet to find out about immunisation, NHS Direct/Choices and Mumsnet were the main websites used, by 36% and 29% of these parents respectively. A notable proportion of the 626 parents used Facebook or Twitter (13%) or chat rooms/discussion forums (6%), highlighting the increasing importance of social media. Parents who used chat rooms or discussion forums for information on immunisation were significantly more likely to say they had seen something that would make them doubt having their child(ren) immunised or persuade them not to immunise (31% compared to 8% amongst all parents). The same was also true for NetDoctor (30%), Patient.co.uk (27%) and Facebook or Twitter (23%).
4. Discussion A key benefit of the tracking surveys is that results can be compared over time, as well as provide a snap-shot of parents’ current views on immunisation and perceptions of new vaccines. This approach is based on parental recall so recall bias or parents providing perceived socially acceptable responses are possible and vaccine status of children cannot be verified. This is, however, a large sample representative of the parental population (see Table 1) and any comparisons between surveys are likely to remain valid with the consistency of method through time. 4.1. Normalisation Our findings suggest that the overwhelming majority of parents in England have their children vaccinated automatically when vaccines are due and this acceptance is at the highest level in more than a decade. This indicates that vaccine hesitancy, defined by the SAGE Working Group as ‘‘delay in acceptance or refusal of vaccination despite availability of vaccination services” [8] is not currently a key issue for parents in England. This is in contrast with other countries where it has been asserted that vaccine refusal is increasing [9]. Our research suggests high parental confidence in vaccination consistent with national data with high vaccine uptake reported by first, second and fifth birthday for routine vaccinations [2]. The importance of difficulties in accessing immunisation reported a quarter of a century ago [10] persists but it is not clear how this may affect specific groups in the population as has been reported elsewhere [11]. In our survey 1.3% of all parents missed an appointment and vaccination was refused in a very small minority of parents. Fewer parents reported postponing immunisations than previously and illness in their child was the main reason for delay, with only 0.5% of all parents delaying due to concerns about vaccines. In their routine discussions health professionals should be aware that practical issues can impede vaccination of a child and, importantly, that most parents accept vaccination, so that they can emphasize this as ‘normal practice’.
4.2. Information exposure Our survey showed fewer parents recalled seeing, hearing or reading about immunisations in general and fewer parents reported anything that would put them off vaccination when compared to 2010 and earlier surveys. In the past the media played a key role in generating public concerns around MMR vaccination and autism [12]. A more considered approach to reporting by the press with more positive or neutral content may now be contributing to greater confidence in the vaccination programme. Whilst parental trust in the media has increased over the last 5 years it remains their least trusted source of information. MMR vaccine continues to be the vaccine that parents are most likely to have postponed or refused, however, alongside flu vaccine. Similarly, of the 11% of parents who indicated there was a vaccine they would not allow a child to have in the future 20% said they would withhold flu vaccine and 16% MMR vaccine; more than double the proportion of parents who indicated any other vaccine. However, these doubts are not currently reflected in their reports of vaccine uptake with only 2% delaying and 1% refusing. Although confidence in the pre-school flu programme is currently less than for other childhood vaccines, it will be interesting to observe if this changes as the programme becomes more routine. 4.3. Information needs Earlier surveys highlighted the crucial role of healthcare professionals in informing and advising on immunisation and supporting parental vaccination decisions [3,13]. Healthcare professionals and the NHS were cited as the most trusted sources of information with trust in all sources increasing between 2010 and 2015. Parents who strongly agreed that they trusted advice provided by health professionals were significantly more likely to have had all immunisations done when they were due. This shows how important the interaction between parents and health professionals can be in building and maintaining confidence in the immunisation programme. Since 2010 significantly fewer parents said they would have liked more information, consistent with greater acceptability and confidence in the immunisation programme. Daily parental Internet use increased in that time and encouragingly a large number of parents used official sources like the NHS Choices website. However, those who used the Internet to obtain information were found to be significantly more likely to delay or refuse vaccination compared to those who did not. Those visiting chat rooms or discussion forums were particularly likely to decline vaccination. Even sites offering well-researched information host discussion forums which can be a platform for minority views not representative of scientific or medical consensus. The influence of social media sites on vaccination decisions has been previously described [14]. Studies have suggested that highlighting the high degree of medical consensus on vaccine safety and effectiveness can be important in increasing public support for vaccination [15,16]; discussion forums could undermine this. 5. Conclusions Parental confidence in the vaccination programme in England is high against a background of increasing trust in the NHS and health professionals. Despite almost all parents seeking information on the Internet, trust in and advice from health care professionals appear to be key factors influencing parental decisions. This strengthens the need to ensure that all those delivering immunisations are well trained and confident when advising parents to vaccinate their child.
H. Campbell et al. / Vaccine 35 (2017) 2979–2985
Conflicts of interest HC and MR work in the Immunisation, Hepatitis and Blood Safety Department which has provided vaccine manufacturing licence holders with post-marketing surveillance reports on meningococcal, Haemophilus influenzae and pneumococcal infections which the companies are required to submit to the UK Licensing authority in compliance with their Risk Management Strategy. A cost recovery charge is made for these reports. AE, LL, JY and HB have no conflicts of interest to declare. Acknowledgements
[5]
[6] [7]
[8] [9] [10]
Public Health England would like to acknowledge Dawn Hands (Managing Director) and Gemma Baker (Research Manager) at BMG Research, who undertook and prepared the report on the 2015 survey into parental attitudes. References [1] Chen RT, Rastogi SC, Mullen JR, Hayes SW, Cochi SL, Donlon JA, et al. The vaccine adverse event reporting system (VAERS). Vaccine 1994;12:542–50. [2] Public Health England. Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme): October to December 2015. Heal. Prot. Rep., vol. 10, no. 12, 2016. [3] Yarwood J, Noakes K, Kennedy D, Campbell H, Salisbury D. Tracking mothers attitudes to childhood immunisation 1991–2001. Vaccine 2005;23:5670–87. [4] Office for National Statistics. [ARCHIVED CONTENT] UK Government Web Archive – The National Archives. Available:
[11]
[12] [13]
[14] [15]
[16]
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nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/guidemethod/geography/beginner-s-guide/census/output-area–oas-/index.html> [accessed 22.06.16]. Office for National Statistics. UK labour market, December 2014. ONS statistical bulletin. Available:; 2014 [accessed 23.06.16]. ‘‘2011 Census, England and Wales.” Available: [accessed 23.06.16]. National Readership Survey. Social Grade | National Readership Survey. Available:
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Changing attitudes to childhood immunisation in English parents Helen Campbell a,⇑, Angela Edwards b, Louise Letley b, Helen Bedford c, Mary Ramsay a, Joanne Yarwood b a
Immunisation, Hepatitis & Blood Safety Department, National Infection Service, Public Health England, 61 Colindale Avenue, London NW9 5EQ, United Kingdom Immunisation, Hepatitis & Blood Safety Dept., National Infection Service, Public Health England, Wellington House, 133-155 Waterloo Road, London SE1 8UG, United Kingdom c UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom b
a r t i c l e
i n f o
Article history: Received 8 November 2016 Received in revised form 27 March 2017 Accepted 30 March 2017 Available online 23 April 2017 Keywords: Immunisation Childhood Acceptability Confidence Vaccination Trust
a b s t r a c t Objectives: We undertook a national survey of parental attitudes to childhood vaccinations and compared results with those in earlier comparable surveys covering a 10 year period. Methods: We randomly selected 275 nationally representative sampling locations in England. Interviewers identified eligible primary care givers (referred to as parents) of children aged from 2 months to <5 years and conducted home-based interviews between January and April 2015. We aimed to recruit 1000 parents of children aged 0–2 years and 1000 of children aged 3–4 years. The questionnaire covered all aspects of the immunisation process, vaccines administered in pregnancy and from infancy to pre-school with a maximum of 86 mixed questions. Results: Interviews were completed with 1792 parents of whom 1130 had children aged 0–2 years and 999 had children aged 3–4 years; 337 had children of both ages. The findings showed that confidence in and acceptance of the vaccination programme was high. Only 2% of parents reported refusing vaccination whilst 90% reported vaccinating their children automatically when due. Almost all parents (97%) had access to the internet and 34% consulted web-based resources for information on vaccination. Parents who used chat rooms or discussion forums for this purpose were significantly more likely to say they had seen something that would make them doubt having their child(ren) immunised (31% compared to 8% amongst all parents). Health professionals and the NHS were seen as the most trusted source of advice on immunisation (90% agreed/strongly agreed with each). Very few parents did not trust these sources (4% and 3% disagreed, respectively). Conclusions: Health professionals remain extremely important in communicating information about vaccination and are highly trusted by parents; a trust that has increased in recent years. Despite most parents seeking information on the Internet, trust in and advice from health care professionals appeared to be key factors influencing parental decisions. Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
1. Introduction The routine childhood immunisation programme in England aims to give every child the opportunity to be protected against vaccine preventable diseases. Immunisation is voluntary and free of charge for all children for every vaccine included in the routine programme. The programme has high uptake rates, with only a very small minority of parents refusing vaccination for their child. As a result, targeted diseases have been markedly reduced with many, including diphtheria, tetanus, rubella, Hib and meningococcal group C disease, now rare and polio eliminated. Maintaining high coverage rates can be challenging in the absence of disease
⇑ Corresponding author. E-mail address: [email protected] (H. Campbell). http://dx.doi.org/10.1016/j.vaccine.2017.03.089 0264-410X/Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
[1] but uptake in England currently exceeds 95% for most vaccines given in infancy and 90% for pre-school boosters offered at around the age of three years four months [2]. National vaccination programmes in England are supported by a long-running series of cross-sectional surveys exploring parental attitudes to childhood immunisation [3]. Even with high uptake parental requirements may change, particularly with revised programmes or new vaccines. To ensure parents’ needs continue to be met it is important to understand their opinion on vaccines and vaccine preventable diseases, their vaccination experiences and what affects their vaccination decisions. This paper presents the views of parents with children under five years of age in the 2015 survey. Differences over the previous 10 surveys running from November 2001 to March 2010 will also be examined with a particular focus on any changes since the previous survey in 2010.
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H. Campbell et al. / Vaccine 35 (2017) 2979–2985
2. Methods
Over time data were based on parents of 0–2 s to ensure comparability.
2.1. 2015 Survey For a nationally representative sample, 275 sampling locations in England were randomly selected. The sampling points were based on two combined 2001 Census Output Areas each containing about 125 households [4]. Sampling was stratified by region and Index of Multiple Deprivation quintile. Census output areas were selected with probability proportional to population size. Interviewers were given quotas for each sampling point by age of child and parental working status. Interviewers identified eligible primary care givers1 (referred to as parent throughout) of children aged from 2 months to <5 years who were willing to participate in a study about the health of young children using door-to-door market research methods. The target was to conduct 1000 interviews among parents of 0–2 year olds and 1000 interviews among parents of 3–4 year olds. Interviewers conducted face-to-face interviews between 19/01/15 and 1/4/15 using Computer Assisted Personal Interviewing. The questionnaire covered all aspects of the immunisation process, vaccines administered in pregnancy and from infancy to pre-school with a maximum of 86 mixed open and closed-ended questions. Some required ‘spontaneous’ or ‘prompted’ answers: the respondent was first asked to give an answer based on spontaneous recall; they then selected from listed possible responses. Responses to open-ended questions were recorded verbatim and ‘coded’ into categories of like responses. To ensure data were representative of parents of children aged 0–4 in England they were weighted by respondent/child age and by region. Targets for age of parent by age of child were taken from the December 2014 Labour Force Survey [5], and region (of households with dependent children aged 0–4) from the 2011 Census [6]. Parents were categorised as ABC1or C2DE social grade according to the occupation of the chief income earner [7]. Data were managed using SPSS (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp). Differences were tested for statistical significance in Merlin (version 9.6.51) using a two-tailed T-test on column proportions. Where a difference was significant at the 95% level, this is indicated. 2.2. Changes in survey methodology over time Prior to March 2003, interviews were carried out with mothers only. Since then primary care givers, whether men or women have been interviewed. Before 2010, surveys included parents of children aged 0–2 years only. From 2010, parents of children aged 3– 4 years were also included, covering the childhood immunisation programme to pre-school. It was at this time that the sample size was increased from 1000 interviews to a total of 2000; with 1000 among parents of 0–2 year olds and 1000 among parents of 3– 4 year olds. The surveys were undertaken at least annually until 2010 and recommenced in 2015. Previously, some questions were divided by parents of children aged 0–2 years old and of children aged 3–4 years old. In 2015, to better reflect the timing of pre-school boosters (offered 3 years after completing the primary infant course, scheduled at 8, 12 and 16 weeks of age) questions were divided according to the age of the child into those for parents of children aged 0–3 years 3 months old (denoted as ‘0y-3y3m’) and parents of children aged 3 years 4 months to 4 years 11 months old (denoted as ‘3y4m-4y’). 1 A ‘primary care giver’ was defined as the person responsible for most decisions about the child’s health care.
3. Results Interviews were completed with 1792 parents of whom 1130 had children aged 0–2 years and 999 had children aged 3–4 years; 337 had children of both ages. Although the methods do not allow ascertainment of the number of eligible households that refused to participate, weighting by respondent age, child age and region was designed to ensure the representativeness of parents of children under five years of age in England (Table 1). 3.1. Immunisation and disease awareness Fifty-one percent (N = 909/1792) of parents recalled seeing, hearing or reading information relating to childhood immunisations in the last year, declining from a 91% peak in 2001 (Fig. 1). Of these, 909 parents 12% (N = 109) spontaneously recalled information that might make them doubt getting their child immunised or persuaded them not to immunise. This was part of an overall decrease in exposure and/or recollection of such information (Fig. 1). Twenty percent (N = 182/909) said the information they recalled concerned the importance of getting children immunised. Doctors/nurses (17%), leaflets (10%), TV in a pharmacy or GP surgery (9%), Internet (6%) were the most common information sources. Mention of most sources fell significantly compared to 2010, other than doctors/nurses. This was consistent with the reduction in national immunisation publicity campaigns using paid for TV and press. Seeking information via the Internet increased from 4% to 6%. When prompted, 12% of all parents (N = 149/1792) recalled seeing, hearing or reading something that made them doubt getting their child(ren) vaccinated. This most often related to nonspecific side effects (23%, N = 34/149), danger of autism/ Crohn’s or ADHD (attention deficit hyperactivity disorder) (16%, N = 24/149) or MMR (measles, mumps and rubella) vaccine (7%, N = 10/149). Thirty-four percent of these parents said that adverse information related specifically to MMR vaccine (N = 51/149) and 26% to flu vaccine (N = 39/149).These parents were most likely to have seen this information on the Internet (32%, N = 48/149) or through speaking to friends, family or other parents (26%, N = 39/149). The diseases perceived to be most serious, rated as ‘very serious’ by the most parents, were Meningitis (82%), Septicaemia (78%), Pneumonia (71%) and Polio (68%). An ear infection was seen as the least serious, rated as ‘very serious’ by 14% of all parents, followed by chickenpox (17%), diarrhoea and vomiting (18%), flu (22%) and rotavirus (25%). 3.2. Decision-making process In 2015, 90% of parents (N = 1613/1792) reported automatically having all their child(ren)’s immunisations done when they were due, a significant increase from 72% of parents (N = 1246/1730) in 2010 (Fig. 2). Mothers were significantly more likely to have refused or delayed an immunisation than fathers (11% compared to 7%). Parents living in the South were also significantly more likely to have refused or delayed (15%) compared to those in the North or the Midlands (both 7%). Seven percent (N = 125/1792) of parents postponed immunisations offered to their child(ren), significantly fewer than in 2010 (19%); of these, 5% immunised later and 2% intended to immunise later (Fig. 2). Forty-two percent of those delaying said that this was
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H. Campbell et al. / Vaccine 35 (2017) 2979–2985 Table 1 The population structure of the unweighted sample achieved by the survey and the adjusted totals by weight/target according to population profiles in England.
a
Category
Characteristic
Unweighted bases
% Unweighted
Target/weighted Bases
% Target/weighted
Gender
Female Male
1468 323
82 18
1460 331
82 18
Age
16–24 25–34 35+
234 930 618
13 52 35
241 926 615
14 52 35
Social grade
ABC1 C2DE
686 1060
39 61
694 1054
40 60
Age of children
Any aged 0y2m to 2ya Any aged 3-4ya
1130 999
63 56
1187 884
66 49
First time primary care giver
1 child onlya More than 1 child (any age)a More than 1 child and all under 5ya More than 1 child and oldest 5+ya
744 1048 354 694
42 58 20 39
791 1001 324 677
44 56 18 38
Ethnicity
White including White other BME
1426 143 362
80
79
20
1413 150 376
21
Working status
Working Not working
913 872
51 49
917 869
51 49
Marital status
With partner Single/Widowed/Divorced/Separated
1387 396
78 22
1387 397
78 22
Disability
Yes No
50 1738
3 97
49 1739
3 97
Region
East Midlands East of England London North East North West South East South West West Midlands Yorkshire and The Humber
143 179 269 108 215 358 143 215 143
8 10 15 6 12 20 8 12 8
142 195 321 88 231 285 159 195 177
8 11 18 5 13 16 9 11 10
Total
1792
1792
These proportions are presented as % of all parents whilst others are presented as % of those providing this information.
Fig. 1. Whether seen, heard or read anything about childhood immunisation recently (among parents of 0–2 s only) and whether this might dissuade you from immunising your child.
due to their child being ill (which equates to 3% of all parents). This was significantly higher among postponing parents aged 25–34 (50%) compared to parents aged 35+ (28%). Eighteen percent of these 125 parents who had postponed immunisations missed the appointment (equivalent to 1.3% of all respondents) and 7% had
concerns about side effects or consequences (equivalent to 0.5% of respondents). Only 2% of parents (N = 43/1792) refused an immunisation offered to their child(ren), compared to 9% in 2010 (Fig. 2). The 43 parents who refused immunisations provided different reasons
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72%
28%
Fig. 2. Whether parents said they had ever refused or delayed any immunisations.
which included; having an objection to the vaccine (N = 9, 21%), concern over reactions and illness after immunisation (N = 9, 20%), safety of immunisations (N = 6, 13%) and their child’s health at the time (N = 5, 12%). Overall 2% of parents said they refused flu vaccine and 1% refused MMR vaccine. Of all 0y-3y3 m parents, 8% (N = 102/1313) weighed up the pros and cons before immunising (Fig. 3, showing parents of 0–2 s), the main consideration was the danger/risk of side effects, mentioned by 47% of these parents (Fig. 4) and by significantly more first time (57%) than experienced parents (41%). Of this small number of parents fewer mentioned MMR in 2015 (65% in 2010 to 50%, N = 41), continuing the recent decline in concerns around MMR vaccine. Only 9% (N = 72) of parents of older children reported weighing up the pros and cons and the proportion of these parents with concerns about MMR vaccine also declined (91% to 54%, N = 39).
3.3. Immunisations that parents would not allow a future child to have Eleven percent (N = 202/1792) of parents said there was a vaccine they would not allow a future child to have, representing a significant decline from 18% of parents in 2010 (Fig. 4). By social grade, ABC1s were significantly more likely to say they would refuse an immunisation for another child in the future (13%) compared to C2DEs (10%). Among the 202 parents, flu vaccine (20%) and MMR vaccine (16%) were those most commonly cited. 3.4. Interactions with health professionals Health professionals and the NHS were seen as the most trusted source of advice on immunisation (90% agreed/strongly agreed with each). Very few parents did not trust these sources (4% and 3% disagreed, respectively). High level trust (strongly agree only)
Fig. 3. Whether automatically had child immunised or weighed up pros and cons (among parents of 0–2 s).
H. Campbell et al. / Vaccine 35 (2017) 2979–2985
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Fig. 4. Issues taken into account when weighing up the pros and cons of immunisation.
Fig. 5. Trust in sources of advice about immunisation over time (among parents of 0–2 s).
in all sources had increased significantly since 2010 (Fig. 5) with the least trusted being the media. Whilst trust in the government was not high (only 33% of parents strongly trusted advice from the government on immunisations) this is also an improvement since 2010. A lower level of trust in the government may not impact on attitudes to the national immunisation programme in England as the NHS and its staff, where trust is consistently strong, are most directly linked with communications and delivery of the programme.
Parents who trusted the advice (strongly agree) given by health professionals were significantly more likely to have had all immunisations done when they were due (93% compared to 85%), whereas less trusting parents were significantly more likely to refuse or postpone (15% compared to 7%). Of 72% of parents who discussed immunisation with health professionals, 47% said they felt more confident about immunising their child and only 3% said they felt less confident about immunising their child after the discussion.
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Twenty-four percent of parents said they would have liked more information about immunisation including: side effects (8%), more/general information (7%), purpose of the immunisation (2%) and vaccine ingredients (2%). This was a significant decline since 2010 when 39% said they would have liked more information. 3.5. The internet and social networks Eighty-four percent of parents used the Internet daily compared to 62% in 2010 and 9% used the internet several times per week; only 3% never used the internet. Sixty-six percent of parents had heard of the NHS Choices website and 45% of all parents had visited it. Of 626 parents (34%) who used the internet to find out about immunisation, NHS Direct/Choices and Mumsnet were the main websites used, by 36% and 29% of these parents respectively. A notable proportion of the 626 parents used Facebook or Twitter (13%) or chat rooms/discussion forums (6%), highlighting the increasing importance of social media. Parents who used chat rooms or discussion forums for information on immunisation were significantly more likely to say they had seen something that would make them doubt having their child(ren) immunised or persuade them not to immunise (31% compared to 8% amongst all parents). The same was also true for NetDoctor (30%), Patient.co.uk (27%) and Facebook or Twitter (23%).
4. Discussion A key benefit of the tracking surveys is that results can be compared over time, as well as provide a snap-shot of parents’ current views on immunisation and perceptions of new vaccines. This approach is based on parental recall so recall bias or parents providing perceived socially acceptable responses are possible and vaccine status of children cannot be verified. This is, however, a large sample representative of the parental population (see Table 1) and any comparisons between surveys are likely to remain valid with the consistency of method through time. 4.1. Normalisation Our findings suggest that the overwhelming majority of parents in England have their children vaccinated automatically when vaccines are due and this acceptance is at the highest level in more than a decade. This indicates that vaccine hesitancy, defined by the SAGE Working Group as ‘‘delay in acceptance or refusal of vaccination despite availability of vaccination services” [8] is not currently a key issue for parents in England. This is in contrast with other countries where it has been asserted that vaccine refusal is increasing [9]. Our research suggests high parental confidence in vaccination consistent with national data with high vaccine uptake reported by first, second and fifth birthday for routine vaccinations [2]. The importance of difficulties in accessing immunisation reported a quarter of a century ago [10] persists but it is not clear how this may affect specific groups in the population as has been reported elsewhere [11]. In our survey 1.3% of all parents missed an appointment and vaccination was refused in a very small minority of parents. Fewer parents reported postponing immunisations than previously and illness in their child was the main reason for delay, with only 0.5% of all parents delaying due to concerns about vaccines. In their routine discussions health professionals should be aware that practical issues can impede vaccination of a child and, importantly, that most parents accept vaccination, so that they can emphasize this as ‘normal practice’.
4.2. Information exposure Our survey showed fewer parents recalled seeing, hearing or reading about immunisations in general and fewer parents reported anything that would put them off vaccination when compared to 2010 and earlier surveys. In the past the media played a key role in generating public concerns around MMR vaccination and autism [12]. A more considered approach to reporting by the press with more positive or neutral content may now be contributing to greater confidence in the vaccination programme. Whilst parental trust in the media has increased over the last 5 years it remains their least trusted source of information. MMR vaccine continues to be the vaccine that parents are most likely to have postponed or refused, however, alongside flu vaccine. Similarly, of the 11% of parents who indicated there was a vaccine they would not allow a child to have in the future 20% said they would withhold flu vaccine and 16% MMR vaccine; more than double the proportion of parents who indicated any other vaccine. However, these doubts are not currently reflected in their reports of vaccine uptake with only 2% delaying and 1% refusing. Although confidence in the pre-school flu programme is currently less than for other childhood vaccines, it will be interesting to observe if this changes as the programme becomes more routine. 4.3. Information needs Earlier surveys highlighted the crucial role of healthcare professionals in informing and advising on immunisation and supporting parental vaccination decisions [3,13]. Healthcare professionals and the NHS were cited as the most trusted sources of information with trust in all sources increasing between 2010 and 2015. Parents who strongly agreed that they trusted advice provided by health professionals were significantly more likely to have had all immunisations done when they were due. This shows how important the interaction between parents and health professionals can be in building and maintaining confidence in the immunisation programme. Since 2010 significantly fewer parents said they would have liked more information, consistent with greater acceptability and confidence in the immunisation programme. Daily parental Internet use increased in that time and encouragingly a large number of parents used official sources like the NHS Choices website. However, those who used the Internet to obtain information were found to be significantly more likely to delay or refuse vaccination compared to those who did not. Those visiting chat rooms or discussion forums were particularly likely to decline vaccination. Even sites offering well-researched information host discussion forums which can be a platform for minority views not representative of scientific or medical consensus. The influence of social media sites on vaccination decisions has been previously described [14]. Studies have suggested that highlighting the high degree of medical consensus on vaccine safety and effectiveness can be important in increasing public support for vaccination [15,16]; discussion forums could undermine this. 5. Conclusions Parental confidence in the vaccination programme in England is high against a background of increasing trust in the NHS and health professionals. Despite almost all parents seeking information on the Internet, trust in and advice from health care professionals appear to be key factors influencing parental decisions. This strengthens the need to ensure that all those delivering immunisations are well trained and confident when advising parents to vaccinate their child.
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Conflicts of interest HC and MR work in the Immunisation, Hepatitis and Blood Safety Department which has provided vaccine manufacturing licence holders with post-marketing surveillance reports on meningococcal, Haemophilus influenzae and pneumococcal infections which the companies are required to submit to the UK Licensing authority in compliance with their Risk Management Strategy. A cost recovery charge is made for these reports. AE, LL, JY and HB have no conflicts of interest to declare. Acknowledgements
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Public Health England would like to acknowledge Dawn Hands (Managing Director) and Gemma Baker (Research Manager) at BMG Research, who undertook and prepared the report on the 2015 survey into parental attitudes. References [1] Chen RT, Rastogi SC, Mullen JR, Hayes SW, Cochi SL, Donlon JA, et al. The vaccine adverse event reporting system (VAERS). Vaccine 1994;12:542–50. [2] Public Health England. Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme): October to December 2015. Heal. Prot. Rep., vol. 10, no. 12, 2016. [3] Yarwood J, Noakes K, Kennedy D, Campbell H, Salisbury D. Tracking mothers attitudes to childhood immunisation 1991–2001. Vaccine 2005;23:5670–87. [4] Office for National Statistics. [ARCHIVED CONTENT] UK Government Web Archive – The National Archives. Available:
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