Dr Richard Roberts, Mr David Morgan, Dr Marko Petrovic and Clare Williams have developed an evidence-based resource to help health professionals explain the facts about MMR vaccine to parents
The Royal College of General Practitioners believes 'it is vitally important that GPs explain to their patients that there is no scientific evidence linking MMR [measles/mumps/rubella] vaccine to autism and Crohn's disease'.1 The challenge of this simple statement is considerable.
A desire to help explain the evidence led our group in North Wales Health Authority in 1998 to produce an evidence-based tool – the MMR Mythbuster – to assist primary care professionals.2 The tool aims to promote effective communication of the facts regarding measles infection and MMR vaccine.
A survey to explore the knowledge, attitudes and practice among primary care professionals relating to the second MMR,3 carried out soon after publication of a paper implying a link between MMR vaccine and autism in 1998,4 revealed the need to support primary care professionals in explaining the rationale for immunisation to parents. It also revealed the fragility of professional confidence during a very turbulent period for MMR in the media. Although a local survey, it is likely that the findings were an accurate reflection of the situation elsewhere in the UK at the time.
Following a series of 'scares' and uncertainty about the evidence, the uptake of MMR vaccine in 2-year-old children in the UK has been declining steadily for several years, with no sign of any significant recovery. In England, uptake fell from 92% in 1996/97 to 88% in 1998/99 (see Figure 1,below),5 and in our health authority from 93% in 1994 to 85% in 1999.
If this situation continues, it will result in a large cohort of children who have no immunity against measles (or mumps or rubella), with the potential at some point for a return of outbreaks to the UK. There is some evidence that this point – the epidemic threshold – may already have been reached in some districts in the UK.6
|Figure 1: Trends in the uptake of MMR and other vaccines at 2 years of age in England and Wales|
The development group consisted of two public health physicians (one a consultant in communicable disease control), the immunisation coordinator (and director of pharmaceutical public health) and a health visitor. Version 1 of the guide was sent to North Wales general practices in 1998, and an updated version (1.1) followed in 2000.
Who is the Mythbuster aimed at?
Although most parents have confidence in the vaccine and have their children immunised, 12% currently do not. This group needs more information to come to an informed decision.
Surveys repeatedly show that the vast majority of parents look first to primary care professionals for advice on immunisation. However, keeping track of the latest piece of research featured in the press, and even dealing with well-known myths in a busy surgery, is a challenge for even the most dedicated primary care professional.
Keeping track of emerging research has been made much easier for busy professionals now that the Department of Health and Health Promotion England have started placing peer-review comment on their websites for those publications likely to result in public concern.7,8 However, the challenge of dealing with well-established and often recycled myths about the MMR vaccine remains.
In addition, 'new research', such as Wakefield and Montgomery's paper re-interpreting research related to the licensing of MMR vaccine,9 is often closely related to established myths, and parents benefit from research being placed in the wider context of the existing evidence base.
Although excellent written resources exist on immunisation and MMR vaccine, these are not designed for use with a parent during a consultation.10-12 Similarly, although there is a wealth of published studies on relevant subjects, and plenty of critical analysis available, this is not easy to recall or describe in an efficient and effective way.
This results in a gap between expert analysis of the evidence and what it is possible to communicate to parents or carers during a brief consultation. It is this gap that the MMR Mythbuster aims to fill, to preserve the quality of information to the point of contact between professional and parent.
Using the Mythbuster in consultations
The MMR Mythbuster is a ring-bound book designed to be used across the table during a consultation with a parent. At the front of the pack is a contents page for easy reference.
The first section of the book contains 10 double-page spreads, arranged such that when the book is laid open across a table, bullet point summary facts face the professional, and supporting graphics and text face the parent sitting opposite.
Parents' concerns do not usually fit neatly into the areas addressed by specific pieces of research. Their concerns are more general; for example, a recent concern is whether the side-effects of MMR have been seriously researched.
The Mythbuster approaches the evidence base from the parents' perspective and identifies 10 common myths about the MMR vaccine (see Table 1, below), which in several cases also apply to vaccination in general.
|Table 1: Myths addressed in the MMR resource pack|
Although a paper resource cannot include emerging research, new research represents only a small proportion of the evidence base, which needs to be considered as a whole.
Figure 2 (below) shows how the Mythbuster presents information to parents to answer concerns that the side-effects of MMR have not been seriously researched, as was recently alleged. 9
|Figure 2: How the Mythbuster presents information to parents to answer concerns that the side-effects of MMR have not been seriously researched|
The second section of the Mythbuster provides evidence-based background notes on each myth, and a key reference list (61 references). Each numbered summary statement in the first section is linked to a numbered background note for the professional in the second section, and the important factual statements in the professional notes are referenced.
How robust is the evidence?
It is the unanimous view of every major professional body in the UK, the World Health Organization, and the governments of at least 33 other European countries, USA, Canada, Australia and New Zealand that the MMR vaccine is the safest way to protect children against measles, mumps and rubella. This is as firm a foundation as we could hope for in making a positive recommendation to wavering parents to have their child immunised with MMR.
However, appropriate professional confidence in the MMR vaccine can also be developed and strengthened by considering the evidence directly. The resource pack presents the evidence base for MMR vaccination (to October 1999) in one readily accessible format, so that doctors and nurses have access to an authoritative reference source without needing to search for the relevant references.
There is no doubt that professionals' confidence in the vaccine is not immune to adverse publicity in the press,13 and the perceived confidence of professionals in MMR vaccine must be an important influence on the parent they are advising.3
How has the pack promoted best practice?
The information is presented in picture and note format backed up by professional notes, which are referenced. This enables users to answer both simple and complex questions and directs users to sources of further information if required.
The format is one that can be used easily by members of the primary care team giving immunisations. No prior knowledge is assumed, although it is suggested that users familiarise themselves with the graphs and tables before first use so that they can explain them easily while being viewed by the parent.
Both the parent and the professional can use the pack at the same time because of the way in which the information is formatted.
In Wales, bilingual (English and Welsh) versions of the pack are available and accessible in all practices, as it is important that users should have information available in their first language. The same principle could be applied elsewhere.
Dissemination of the resource pack was backed up by local education and training activities; these were held both centrally and within local practices and clinics, and were led by consultant community paediatricians.
Any part of the pack can be copied for parents to take away, so the dedicated parent can trace the evidence underpinning this important decision for their child's future back to the original research.
How has the pack improved patient care?
We undertook an evaluation of the Mythbuster between June and October 2000, using a self-administered postal questionnaire mailed to a random sample of 40% of general practices in north Wales. A Likert scale (a scale of responses to a question ordered in a hierarchical sequence) of 1–5 was used.
Although addressed to GP principals, recipients were asked to pass the questionnaire on to whoever takes main responsibility for immunisation in the practice.
The response rate was 74% (42/57):
- 55% (23/42) of respondents were GPs
- 14% (6/42) were health visitors
- 19% (8/42) were practice nurses
- 12% (5/42) were not identified
- 14% (6/42) stated that they had not received the Mythbuster.
This left 36 respondents for analysis:
- 83% had used the Mythbuster with patients
- 80% considered the pack useful or very useful for advising parents of the facts about MMR vaccine
- 83% rated the pack easy or very easy to use
- Only 3% (1 respondent) thought the contents were difficult for parents to understand
- The format and quality of illustrations were rated good or excellent by 78% and 83% respectively
- 95% considered the amount of detail provided in the professional notes to be about right.
Finally, respondents were asked, in terms of personal learning, how much of an impact the Mythbuster had had on their knowledge, skills and personal views. On a scale of 1 (none at all) to 5 (a lot), respondents scored its effects in three areas (see Table 2, below).
Table 2: Impact of the MMR Mythbuster, in terms of personal learning,on the knowledge, skills and personal views of professional users (n=36)
|1 or 2||14%|
|4 or 5||47%|
|1 or 2||25%|
|4 or 5||25%|
|1 or 2||31%|
|4 or 5||22%|
|Key to Likert scale: 1=none at all; 5=a lot|
Since its launch 3 years ago, the MMR Mythbuster has been revised and updated, and thanks to the National Assembly will be available in all practices in Wales early in 2001. As a result of other local initiatives, it is also in use, or being considered for use, in several other parts of the UK.
It is our experience, from using the pack, that most parents with specific concerns about the MMR vaccine, if given the facts on which to base an informed decision and positive support, will decide to give their child the vaccine.
For further information on the MMR Mythbuster resource pack, contact Dr Richard Roberts by email at email@example.com or by post to: Department of Public Health, North Wales Health Authority, Hendy Road, Mold, Flintshire CH7 1PZ.
- Fleming D. Royal College response to uptake of the MMR vaccine (press release). London: RCGP, 2001. Internet page at http://www.rcgp.org.uk/rcgp/press/2001/9133.asp (accessed 19.01.01)
- Roberts RJ, Morgan DA, Petrovic M, Williams C. MMR Mythbuster. Mold: North Wales Health Authority, 1999. ISBN 1-902844-02-5.
- Petrovic M, Roberts R, Ramsay M. Health professionals and the second MMR vaccine. Br Med J 2001; 322: 82-5.
- Wakefield AJ, Murch SH, Anthony A et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351: 637-41.
- Immunisation Coverage Statistics. Public Health Laboratory Service. Internet page at http://www.phls.co.uk/facts/Vaccination/cover.htm (accessed 20/3/01).
- White J. Is measles coming back? Implications of falling MMR. Conference on the Epidemiology and Control of Infectious Disease and Environmental Hazards. London, November 2000.
- Health Promotion England. MMR – linked to autism? No association found between MMR and increasing occurrence of autism. London: HPE, 2001. Internet: http://www.immunisation.org.uk/autism.html
- DoH. Measles, Mumps and Rubella Vaccine (MMR). London: DoH, 2001. Internet: http://www.doh.gov.uk/mmr.htm
- Wakefield AJ, Montgomery SM. Measles, mumps, rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-83.
- DoH. Immunisation against Infectious Disease. London: HMSO, 1996.
- Health Education Authority. Measles, Mumps and Rubella Vaccine. London: HEA, 1997.
- Health Education Authority. MMR Factsheet (2). London: Department of Health, 1998.
- Roberts N. Why are practice nurses scared of MMR2? GP 1998; January 23: 63.
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