Facing the challenges of low vaccine uptake: a practice nurse’s view

As reported in Practice Nurse last month, Totnes in Devon holds the dubious honour of having one of the lowest vaccine uptakes in England. Practice nurse Katie Trollope explains how her surgery is trying to overcome vaccine hesitancy

If I was writing for a travel journal I would promote a visit to Totnes as ‘an experience not to be missed.’ Nestled within the green rolling Devon-dumpling hills on the edge of the River Dart, Totnes is a thriving market town with a delightfully un-uniform high street where chain stores are a rarity and independent shops prevail. A visit to the bustling weekly markets provides an opportunity to fill the senses with music played by a variety of enormously talented buskers, indulge oneself in the professedly relaxing and blissful experience of ‘Gong bath mediation’, inhale the wonderful aromas of food from around the world or explore the miscellany of natural health and alternative therapy shops and stalls.

Among the Totnes population there is a well-established community holding strong beliefs in alternative treatments such as acupuncture, homeopathy, reflexology and hypnotherapy. Working within this community very often offers a positive influence on our work in primary care, bringing refreshing views on health, lifestyle and well-being, and an abundant supply of complementary therapies in the locality. Alternative views on vaccination and immunisation, however, present big challenges to our team at Leatside Surgery.

Recently, this notoriously inflammatory and polarising issue has once again sparked intense debate following the publication in September of the Childhood Vaccination coverage statistics for England 2018-2019,¹ which showed numbers dwindling to below the levels required to achieve herd immunity. This is of particular concern for us in the Totnes area with our uptake statistics for vaccination being lower than the national average, thereby jeopardising our local herd immunity and putting our community at risk.

Addressing vaccine uptake

Over the years, the surgery has met with various members of the screening and immunisations team and is very engaged with addressing vaccine uptake. Practical steps have been taken to improve access to immunisation clinics. We offer flexible clinic appointment times and send out invitations to parents with a reminder call from the practice 48 hours prior to the appointment to confirm attendance. The GPs discuss vaccination with parents at the six-week check, providing leaflets and the opportunity to discuss issues in further detail if they have concerns. We provide leaflets and posters and use our waiting room TV screens to promote vaccination.

Historically, the accusatory and judgmental attitudes on both sides of the vaccine debate have blocked the opportunity to have a reasonable discussion about the benefits and risks of vaccination, and subsequently get to the truth of the matter, and address peoples’ genuine concerns. Many of our patients who refuse vaccination are frequently well-educated, articulate and knowledgeable individuals who oppose vaccination on a number of levels, and I find they can be the most difficult to reach. At Leatside we have tried to ‘bridge the gap’ by offering patients the opportunity to come for an informal discussion to answer any queries in a non-judgmental consultation. In the past 6 months, we have written to parents of children who have had no immunisations, or have incomplete immunisation status in the 4-5 year age range, offering the opportunity to catch up, and also to parents of children aged 10-11 years, encouraging attendance for MMR vaccines. The letters emphasise our availability and willingness to discuss concerns about vaccines.

Although the conversations we have with parents who are assiduously against vaccination can be uncomfortable, especially when faced with on-the-spot challenges based on their own research, I find it is crucial to acknowledge and respect their beliefs in order to build rapport and mutual respect. This concept is enshrined in The 2015 Nursing and Midwifery Council Code:² ‘Listen to people and respond to their preferences and concerns’. The Code highlights the need to help patients recognise and respect their contribution to their own health and well-being; to encourage and empower them to share decisions about their treatment and care and to respect a person’s right to accept or refuse care and treatment.

Natural approach

When chatting to parents who are uncertain about vaccination, I’ve found it useful to emphasise that paradoxically, immunisation is a far more natural approach to medicine compared to using synthesised chemical medicines, stimulating a child’s immune system to protect against a disease using a safe, weakened form of the virus or bacterium, as opposed to the very real threats of the actual diseases. It can be useful to point out to parents who take this ‘natural’ stance or who prefer low intervention with regards to vaccination that vaccination is supported by the British Homeopathic Association, which states: ‘There is no evidence to show that homeopathic medicines can be used instead of vaccination. The Faculty of Homeopathy recommends that immunisation is carried out in the usual way, unless there are strong medical contraindications.’³ This message can be reassuring for patients who have heard negative messages, often through social media, regarding ‘conspiracy theories’ relating to vaccination, and theories of subterfuge by the pharmaceutical industry.

The reasons why people refuse vaccination are multiple, and complex. They often vary with the local context, the scares of the day and the personal history of the individuals involved.⁴ Vaccination has been so successful that the diseases targeted are now scarce, so we are no longer faced with the perilous consequences of the damage they can cause. Consequently, the benefits of vaccination can seem somewhat intangible while the potential risks of vaccinations may appear far more real, visible and immediate – and this is what many parents focus on.

Establishing connections and developing therapeutic relationships with patients is instrumental to the process of improving vaccine uptake. Health professionals are trusted sources of advice about vaccinations and we have a responsibility to ensure parents are appropriately informed. We need to deliver a clear, positive and confident message that vaccines work and save lives. The concept of herd immunity should be explained and that low vaccine rates put our community at increased risk, especially vulnerable members of the community who are unable to receive vaccines and rely on herd immunity for protection.

Tackling parental concerns 

Addressing parental concerns about safety related issues such as multiple vaccines, the use of adjuvants and the most common side-effects of vaccinations is essential. We direct parents to The Vaccine Knowledge Project,⁵ managed by the Oxford Vaccine Group, an academic research group in the Department of Paediatrics at the University of Oxford. This excellent resource is beneficial for parents who wish to read around the topics to aid their decisions. Even though advice may go unheeded or even be unwelcome, parents can change their minds about previous decisions.⁶ Patients are reminded they can return for vaccination at any point if they change their mind.

Central to a successful consultation with patients about vaccinations is communication, encompassing active listening and both verbal and non-verbal cues. Using a model such as Pendleton’s new consultation⁷ provides structure and builds the relationship. Establishing a connection and developing a therapeutic relationship aids the decisions made by patients.

As a practitioner running regular immunisation clinics, the idea of compulsory vaccination fills me with great concern, as I believe parental consensus should be preserved.

Our current approach of supporting patients, providing them with opportunities to debate the issues surrounding vaccination, giving them clear scientific facts about how they work and crucially a clear message about the risks of not getting vaccinated is the way forward. It is greatly rewarding to see the success of this approach when a parent changes their viewpoint and decides to vaccinate their child. It does happen, it just needs to be more often!

REFERENCES

1. NHS Digital. Childhood vaccination coverage statistics- England 2018-2019; 26 Sep 2019. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-immunisation-statistics

2. Nursing and Midwifery Council. The code: Professional standards of practice and behaviour for nurses and midwives. London: Nursing & Midwifery Council; 2015

3. British Homeopathic Society. Immunisation; 2013. https://www.britishhomeopathic.org/mediacentre/position_statementsimmunisation/

4. Fear of the Needle. The Biomedical Scientist. 2019 https://thebiomedicalscientist.net/science/fear-needle

5. Vaccine Knowledge Project. Authoritative Information For All. https://vk.ovg.ox.ac.uk/vk/

6. Bedford H, Elliman D. Fifteen-minute consultation: Vaccine hesitant parents. Arch Dis Child – Education & Practice; 2019 ePub 01 October 2019..

https://ep.bmj.com/content/early/2019/09/29/archdischild-2019-316927

7. Pendleton D, Schofield T, Tate P, Havelock P. The New Consultation: Developing Doctor-Patient Communication. Oxford: Oxford University Press; 2003