Talking with parents about immunisation

Art & science

The synthesis of art and science is lived by the nurse in the nursing act

JOSEPHINE G PATERSON

Talking wiTh parenTs abouT immunisaTion Helen Donovan and Helen Bedford offer communication strategies for health professionals and practical advice on where to access resources Correspondence [email protected] Helen Donovan is public health adviser RCN, specialist nurse in health protection and immunisation Helen Bedford is senior lecturer in children’s health, UCL Institute of Child Health, London Date of submission January 21 2013 Date of acceptance January 29 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines www.primaryhealthcare.net

abstract This article is aimed at all those involved with immunisation. It is important that everyone who provides parents and carers with information about immunisation knows where and how to get useful and, more importantly, reputable resources and information to support parents. This includes those involved in giving vaccines as well as those advising and discussing immunisation. Maintaining trust in the programme is paramount and staff have to be up to date and knowledgeable. The vaccination rate in the UK is rising, which suggests that parents are generally satisfied with the immunisation process. There is, however, still room for improvement and evidence to suggest that a significant proportion have criticisms. These mainly relate to the information given being biased, unbalanced or inconsistent. It is sometimes difficult to discriminate between authoritative evidence-based sources and those based on anecdote and misinformation that often adopt an anti-vaccination position. It is important that health professionals do not underestimate the power of these negative messages. This article discusses how to respond to some frequently asked questions and where staff can go to access useful and reliable information and where to direct parents and carers to look. Keywords Immunisation, communicating with parents and carers, accessing reputable information, maintaining trust in the immunisation process, public health, child health

16 May 2013 | Volume 23 | Number 4

in view of the proven safety and effectiveness of immunisation vaccines in protecting children from infectious diseases (world health organization 2012), it can be surprising how much time is required to advise and reassure people about their safety and benefits. This is, in part, due to the success of immunisation programmes; as the diseases become uncommon the public increasingly turns its attention to the rare risks of the vaccines (Cooper et al 2008), or even to unfounded safety concerns which amount to no more than myth. The high immunisation rates in the uk for the primary and measles, mumps and rubella (mmr) vaccines might suggest that parents are totally satisfied with the immunisation process. however, since a significant proportion of parents have criticisms, there is room for improvement. These criticisms mainly relate to the information given, either that it is insufficient or that it is biased or unbalanced (Yarwood et al 2005, bedford and lansley 2006). as a result, parents often turn to the internet only to find a plethora of conflicting, inaccurate and unregulated information (scullard et al 2010). it is understandable that many parents and, even some health professionals, find it difficult to discriminate between authoritative evidence-based sources and those based on anecdote and misinformation which often adopt an anti-vaccination position. health professionals should not underestimate the power of these negative messages; viewing anti-vaccination comments on the internet has been demonstrated to have a significantly adverse effect on parents’ perception of the risks versus benefits of vaccination (betsch et al 2010).

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Art & science | vaccination an important task for health professionals is to engage effectively with parents and carers. This includes advising them about the immunisation programme, answering their questions and concerns, and directing them to authoritative sources of information. until established otherwise, it should be assumed that all parents have questions because not only those who reject vaccines voice concerns (raithatha et al 2003, Casiday et al 2006). similarly, attendance at the immunisation clinic does not necessarily indicate that parents do not want or need a discussion (mcmurray et al 2004). however, it is not simply a question of giving parents more and more information. Trust in a health professional has been found to be pivotal in determining whether parents accept immunisation for their child (benin et al 2006) and, while being knowledgeable about the scientific issues is important, it is only one of a number of characteristics that parents recognise as being indicative of a health professional’s trustworthiness. The nature of the communication is critical, with parents valuing the health professional who treats them as an individual, spends time with them, seeks out and listens to their questions, is empathetic to their concerns – however misguided they may seem – and avoids pressurising them into accepting immunisation (benin et al 2006). satisfaction with the immunisation visit may have the important knock-on effects of making it more likely that the parent will return for subsequent vaccine doses and to complete the schedule. nurses and other healthcare staff working in primary care settings invariably feel they do not have enough time to adequately answer parents questions and address any concerns. Time spent doing this, certainly in the early days, can help ensure parents return for their subsequent vaccination appointments and potentially save time on following up on missed appointments.

Are vaccines safe? as vaccines are given to a whole population, primarily healthy individuals, it is understandable that this tops the list of parental concerns. vaccines undergo rigorous safety trials before being licensed and, once in use, vaccine safety continues to be monitored through the yellow card system. This system enables early detection of emerging drug safety hazards and routine monitoring for all medicines in clinical use (www.mhra.gov.uk). if a safety ‘alert’ occurs as the result of a pattern of yellow card reports, or scientific publications trigger concerns (for example wakefield et al 1998), specific studies will be conducted. Forewarning parents of the common side effects following a vaccine, such as soreness and swelling at the injection site or a low grade fever, and how to manage these, may reduce their anxiety. it is particularly important to advise parents about the likely adverse effects of mmr vaccine as they appear later than other vaccines, at seven to ten days for the measles and 21 days for the mumps components. prophylactic administration of anti-pyretics is not recommended and these are only indicated if the child appears to be distressed (richardson and lakhanpaul 2007). The Department of health’s leaflet ‘what to expect after vaccinations’ provides useful advice for parents to support this discussion (tinyurl.com/36hg6lx).

Parents’ questions

I am worried that giving all these vaccines together will be too much for my baby’s immune system From the moment they are born, babies are exposed to a multitude of things that stimulate their immune system. This is how it matures. in comparison, the number of antigens in vaccines is relatively small and they are given in a controlled manner. There is no evidence that vaccines harm the immune system, whether that is by making a child more prone to other infections (stowe et al 2009), or by increasing rates of allergic or autoimmune conditions (offit and hackett 2003).

research and experience highlight the issues that comprise parents’ frequently asked questions about immunisation (kennedy et al 2011). They include a limited number of themes, allowing health professionals to be prepared. it is important that health professionals’ responses are tailored to take account of individual parent’s particular concerns and level of understanding. listed below are some of the most frequently asked questions, along with suggested responses and where to find additional information:

These diseases have all disappeared so why bother with the vaccine? The incidence of many diseases has declined because of vaccination. however, there are many examples of reduced vaccine uptake resulting in the re-emergence of diseases, for example whooping cough in the mid 1970s and measles in the 2000s. while a disease continues to circulate, anywhere in the world, it is important to maintain vaccine uptake.



Sources of information As a general guide to searching the web for information ask, and encourage patients, parents and carers to ask: ■■ Who or what is behind the information? ■■ Is the information biased, possibly selected to present one viewpoint? ■■ Does the author have a vested interest in the information presented? ■■ Is it dated? There may be more current advice available. ■■ Is it referenced and are uncertainties acknowledged? Look for websites providing reliable and trustworthy health information that have the Health on the Net (HON) code seal: www.hon.ch/HONcode/Patients/intro.html Useful and reputable websites: ■■ The Department of Health website has now moved and is included as a series page within the government information and web pages: www.gov.uk/government/organisations/public-health-england/ series/immunisation The page has links to the ‘Green Book’, useful publications, ImmForm and has a link to the previous information channel. ■■ Information for parents is available from NHS Choices: www.nhs.uk/planners/vaccinations Information from this website can be printed off to give to patients. Public comments on this website are not moderated. ■■ Health protection advice for the UK: Public Health England (formerly Health Protection Agency): www.hpa.org.uk Health Protection Scotland: www.hps.scot.nhs.uk Health Protection Wales: www.wales.nhs.uk/sites3/home.cfm?orgid=457 Health Protection Northern Ireland: www.publichealth.hscni.net/directorate-public-health/ health-protection Why do we need to vaccinate babies when they are so young? vaccines are given to prevent the spread of infectious diseases that could make children very ill, cause permanent side effects or even result in death. Delaying vaccination leaves a child at risk for longer than necessary. For whooping cough and haemophilus influenzae type b (hib) this can be particularly dangerous. babies who catch whooping cough under the age of six months are more likely to be seriously ill, and about 75 per cent of deaths are in infants under three months of age (Campbell et al 2012); the peak age for an attack of hib disease is between six and 12 months of age (Clements et al 1993).

See the Public Health England (HPA) migrant guide for general advice on health related issues for individuals moving to the UK: www.hpa.org.uk/MigrantHealthGuide ■■ Great Ormond Street Hospital immunisation website has useful links to a range of information and FAQs: www.gosh.nhs.uk/parents-and-visitors/general-health-advice/ immunisation ■■ Oxford Vaccine Group. This site aims to inform parents about vaccine-preventable diseases and has films about decision making: www.ovg.ox.ac.uk/vaccine-knowledge-home ■■ Meningitis Research Foundation gives general information: www.meningitis.org It also produces Vital signs Vital Issues: Recognition and Prevention of Meningitis and Septicaemia, Help for community practitioners: www.meningitis.org/assets/x/50189 ■■ Meningitis Trust: www.meningitis-trust.org ■■ National Travel Health Network and Centre www.nathnac.org ■■ Centers for Disease Control and Prevention vaccination pages*: www.cdc.gov/vaccines ■■ The Children’s Hospital of Philadelphia Vaccination Education Center* www.chop.edu/service/vaccine-education-center ■■ The World Health Organization (WHO): www.who.org The WHO interactive website to help identify each country’s immunisation schedule: http://apps.who.int/immunization_monitoring/en/globalsummary/ scheduleselect.cfm * NB It is important to remind parents that some information may differ due to different scheduling in the US.

I have heard the additives and other vaccine contents can be harmful vaccines are prepared in a variety of ways and different vaccines contain different additives. These may be used as preservatives to stop the growth of foreign bacteria, stabilisers to improve the shelf-life, or adjuvants to help the vaccine work more effectively. while a number of additives may well be toxic in large amounts, as are some vitamins, all the evidence shows that they do not cause harm in the doses used (offit and Jew 2003). To answer specific questions, health professionals need to know what the routine vaccines contain or where to find out, for example,

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Art & science | vaccination from the electronic medicines Compendium (emC) (www.medicines.org.uk/emc).

Information The responses we have outlined are of necessity brief and many parents will want more detail. it is important to make sure their concerns are answered in full. have information available for them to access, and further sources of information such as a list of reliable internet sites (box 1). Detailed responses to these and other questions are available on the great ormond street website with the relevant research articles available for those parents who want more detailed evidence. health professionals should be honest if they do not know the answers to questions and say so, but seek further information for the parent. Trying to give advice when unsure may lead to further confusion. some parents may want time to consider your advice, so do not pressurise for a decision. however, setting a date for further discussion prevents matters drifting. Finally, if parents decide not to have their child immunised, this is their decision. it is important not to cross the boundary between discussion and argument. Document this in the records and explain that you are recording it. make sure they know they can always change their mind so ‘keep the door open’ by letting the parent know you would be happy to discuss the issue further at a later date.

Conclusion although most parents have their children immunised, some of them, as well as those who decline immunisation, express concerns (stefanoff et al 2010). These may be exacerbated by the plethora of misinformation on the internet. it is important that a trusted professional gives parents time to voice their concerns and then addresses them in a manner appropriate to the individual situation. a small number of questions account for most parental concerns, and information about these should be available at all consultations. For less common concerns it may be necessary to seek out the information and return to the parent when found. Critically, good communication by health professionals is not simply a question of giving copious amounts of information to parents; its importance in maintaining the success of the immunisation programme cannot be over-estimated. indeed, good communication by health professionals is one of the important elements that maintains people’s trust in immunisation (Cooper et al 2008). Join the debate online Are health practitioners doing enough to communicate the importance of childhood vaccination? Go to www.primaryhealthcare.net to vote.

online archive For related information, visit our online archive of more than 7,000 articles and search using the keywords Conflict of interest None declared

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