Published in Health News and Evidence
Date published: About this date
The latest report on immunisation rates by the National Health Performance Authority has once again highlighted the issue of under-vaccination in Australian communities.
While the media and politicians are clamouring for mandatory vaccination schemes and changes to State laws, healthcare professionals are dealing with concerns of parents, some of whom feel marginalised and alienated for their strongly held views against vaccination, and others who may simply have forgotten their child’s vaccinations were due.
Most health professionals agree that a high rate of vaccination in the community is vitally important to ensure the continued health of Australians. How can you contribute to increasing the rate of vaccination in your area?
How can you improve vaccination rates in your area?
- Interactions with health professionals have been identified as critical in shaping a parent’s attitude to vaccination.
- Address parental concerns, as this may motivate hesitant parents toward acceptance, while poor communication may contribute to vaccine refusal.1
- Methods to remove barriers to immunisation include:
- providing reminders and opportunistically enquiring about immunisation status
- providing catch-up immunisations
- being aware that recent migrants may not know there are differences in immunisation schedules between countries.2
- Aboriginal and Torres Strait Islander peoples experience higher rates of infectious disease, and additional vaccinations are recommended for them.3
- Actively promote vaccination to your patients who identify as Aboriginal and Torres Strait Islander.
A recent report from the National Health Performance Authority (NHPA) has resulted in a large amount of media and political attention. The report highlighted that across Australia around 77,000 children were not fully immunised for their age against vaccine-preventable diseases in 2011–12.4
Even more worrying, NHPA’s report showed that in some areas the vaccination rates were below those necessary to establish ‘herd immunity’.4 For example, the WHO advocates an immunisation rate of 93–95% of the population to ensure measles elimination.4 In some areas of Australia levels of complete immunisation are as low as 84% at age 5, and down to 71% in some Aboriginal and Torres Strait Islander children.4
In response to this report and growing pressure from the media,5 NSW politicians will be voting to change State law. As of January 2014 it is proposed that childcare centres will be required to confirm immunisation status of children before they are enrolled.6
The NHPA report
Overall Australia has very high and stable vaccination rates, with around 92% of children being fully vaccinated.7,8 The NHPA looked in more detail at the Medicare Local catchments to investigate whether there were local differences in vaccination rates and whether vaccination rates among Aboriginal and Torres Strait Islander children differed from those in the rest of the community.
The report found that, while most Medicare Local catchments had very high vaccination rates, there were a number that had very poor rates. They also found that, in general, Aboriginal and Torres Strait Islander children had lower rates of vaccination.
Medicare catchments such as North Coast (NSW) and Eastern Sydney (NSW) had vaccination rates below the national average and were potentially at a higher risk of outbreaks than communities where vaccination rates meet the criteria for herd immunity.4 This is a concerning statistic, given the recent outbreaks of whooping cough and measles in Australia,9-11 and the risk this poses to children too young to be immunised, unable to be immunised and those who are immune compromised.4
Why are some children not vaccinated?
The media response to the NHPA report suggested that reasons for under-vaccination ranged from refusal by some parents to allow their children to be vaccinated to, in some cases, children’s vaccination schedules interrupted by overseas holidays.12
The actual reasons for children not being vaccinated are complex, and there are numerous challenges to ensure full vaccination of children, for example:
- the routine schedules are becoming more complicated and are subject to frequent change2
- the pressure to vaccinate is lessening as vaccine-preventable diseases become increasingly uncommon2; and as the risk from the disease diminishes, the perceived risk of the vaccine may increase
- there is also organised opposition to vaccination from groups using the internet to spread their message.13
A study in the UK examined the reasons behind either incomplete immunisation or lack of immunisation in some children.14 In this study 3.3% of children were partially immunised and 1.1% remained unimmunised.
There was a difference in the types of reasons cited for the under-vaccination. Parents of partially immunised children more frequently cited medical reasons, such as previous allergic reaction to a vaccine, or immunosuppression, while beliefs and attitudes were more frequently cited as reasons for parents of unimmunised children.14
Overall in the literature there appear to be two overarching parental factors associated with under-vaccination:
- socioeconomic factors: lack of access or resources to overcome barriers such as transport, time off work and childcare1,15
- parental concerns about the safety of vaccines.1
Aboriginal and Torres Strait Islander peoples are at a greater risk of infectious disease.3 Their overall immunisation rates are high;3 however, the NHPA report showed that in some areas the vaccination rates in these communities are lower than the average.4 Other research has shown that vaccination is more frequently delayed in Aboriginal and Torres Strait Islander children.3
Vaccination rates may be improved through use of systems to accurately record whether a person identifies as Aboriginal and Torres Strait Islander, and to schedule regular preventive activities. These systems might increase the chances of opportunistic vaccination and could be used to provide timely reminders to prevent delays in vaccination.3
Five archetypes of parental attitude to vaccination have been identified and characterised to help healthcare professionals tailor their communication, based on the beliefs and attitudes of the parent1 (Figure 1).
A communication framework was developed to help GPs tailor their conversations about vaccination depending on the parents’ views on the issue.1 Using the parental archetypes in Figure 1, different types of communication styles and treatment goals were proposed to help ensure children receive all recommended vaccines.
When discussing vaccines with parents, building trust is a key goal. Clarification of parental concerns, while avoiding the temptation to minimise or dismiss concerns, is important.1
A guiding style of communication may be useful, while avoiding being directive. For example, inform parents about the benefits and risks of vaccination but avoid overstating the safety. Avoid discrediting information sources and using jargon.
Simply stating facts and statistics may not be enough to convince some parents. A story of a single child affected by under-vaccination may move people to action more effectively than statistics, even with compelling evidence.16
Acknowledge parental concerns while determining the readiness for change and providing appropriate resources to support evidence-based decision making.1
Table: A framework for improving vaccine uptake1
||Present for vaccinations when due.
||Child vaccinated and parent positive about decision.
||Fully vaccinated child.
||Child vaccinated and parent positive about decision.
||Accept questions and concerns
Use verbal descriptions of vaccine and disease risks — numerical descriptions are also useful; these can be. percentages or natural frequencies
Explain the common and rare side effects.
Be flexible in addressing parents’ concerns.
||Present on time or slightly late.
||Child vaccinated and parent positive about decision.
||Use a guiding style of communication
Acknowledge concerns and empathise.
||Fully or partially vaccinated child
Present for vaccines late.
|This group may need the most time to discuss concerns but are most likely to change behaviour.
||Provide risk–benefit information
Use decision aids if applicable
Allow parent to return to discuss concerns.
Present for another reason.
|Parent prepared to think about vaccination and attend clinic to discuss further.
Feels positive about encounter — that concerns have been listened to.
Parent is aware of the risks of non-vaccination.
|Avoid back-and-forth debate about vaccination.
Ask the parent about their feelings on the importance of protecting their child against infectious disease and their confidence in the vaccine to do this.
Explore whether the parent would find a selective regimen acceptable
Leave the door open for further discussion
- Leask J, Kinnersley P, Jackson C, et al. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatr 2012;12:154. [Pubmed]
- Royal Australasian College of Physicians. Paediatrics & Child Health Division. Immunisation Position Statement, October 2012. http://www.racp.edu.au/page/paed-policy (accessed 19 May 2013).
- Australian Government Department of Health and Ageing. The Australian Immunisation Handbook 10th Edition 2013. 2013. http://www.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-3-1 (accessed 7 June 2013).
- National Health Performance Authority. Healthy Communities: Immunisation rates for children in 2011 - 2012. NHPA, Sydney: 2013. http://www.nhpa.gov.au/internet/nhpa/publishing.nsf/Content/Healthy-communities/$file/HC_ImmRates_2011-12_FINAL_130409.pdf (accessed 16 May 2013).
- The Australian. Our No Jab No Play plan won over Health Minister Jillian Skinner - May 22 2013. 2013. http://www.theaustralian.com.au/news/health-minister-jillian-skinner-to-get-tough-on-vaccines/story-e6frg6n6-1226647198894 (accessed 22 May 2013).
- Jillian Skinner. NSW government boosts childhood vaccination laws. 2013. http://www0.health.nsw.gov.au/news/2013/20130528_00.htm (accessed 28 May 2013).
- National Centre for Immunisation Research and Surveillance. Childhood Immunisation Coverage Estimates. 2013. http://ncirs.edu.au/immunisation/coverage/estimates/ (accessed 22 May 2013).
- Hull B, Dey A, Mahajan D, et al. Immunisation coverage annual report, 2009. 2009. http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi3502-pdf-cnt.htm/$FILE/cdi3502b.pdf (accessed 7 June 2013).
- Chief Health Officer Victoria Australia. Measles cases in Melbourne - alert for health professionals - 22 May 2013. 2013. http://www.health.vic.gov.au/chiefhealthofficer/alerts/alert-2013-05-measles.htm (accessed 7 June 2013).
- NSW Health. Measles cases declining but vigilance urged. 2012. http://www.health.nsw.gov.au/infectious/pages/measles.aspx (accessed 7 June 2013).
- Immunise Australia Program. Pertussis (Whooping Cough). 2013. http://www.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-pertussis (accessed 16 May 2013).
- Corderoy A. Lower vaccine rates put wealthy areas at risk - April 11 2013. Sydney: Sydney Morning Herald, 2013. http://www.smh.com.au/nsw/lower-vaccine-rates-put-wealthy-areas-at-risk-of-disease-20130410-2hlt5.html (accessed 22 May 2013).
- Kata A. Anti-vaccine activists, Web 2.0, and the postmodern paradigm--an overview of tactics and tropes used online by the anti-vaccination movement. Vaccine 2012;30:3778–89. [Pubmed]
- Samad L, Butler N, Peckham C, et al. Incomplete immunisation uptake in infancy: maternal reasons. Vaccine 2006;24:6823–9. [Pubmed]
- Samad L, Tate AR, Dezateux C, et al. Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. BMJ 2006;332:1312–3. [Pubmed]
- Diekema DS. Improving childhood vaccination rates. N Engl J Med 2012;366:391–3. [Pubmed]