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Annual increments in measles, mumps and rubella (MMR) vaccination coverage in England have halted, with uptake rates (mean 85%) remaining below the 95% rate needed for herd immunity.1 Some commentators have called for vaccination to be made compulsory, or otherwise heavily incentivised. Two schemes were recently debated in the UK press: MMR vaccination as a requirement for school entry (a form of “compulsory vaccination”),2 or the withholding of welfare payments from parents of non-vaccinated children (“incentivised vaccination”).3
Intervention effectiveness is partly determined by acceptability among target populations. We explored views towards these two schemes among (A) parents of children under 5 years and (B) health visitors (community-based health professionals). Focus groups were conducted with five parent-and-toddler groups (28 parents in total, of whom 20 were mothers and 3 had not vaccinated their children; mean age 33 years), and individual interviews with six health visitors, in London in Summer 2008. Participants were given written descriptions of the interventions (available from the authors) and asked whether these would be, or would have been, helpful.
Thematic analysis of verbatim transcripts was performed by BG, with interpretation verified by JM, AD and SM. Results revealed mostly objections to the schemes, on ethical, ideological and practical grounds. Rare positive responses were noted among two parents who emphasised negative consequences of non-vaccination.
Most parents and all health visitors were opposed to a perceived disempowerment of parents via removal of consent. Withholding welfare payments was expected to impact disproportionately on low-income families. There were also objections to penalising parents unwilling to vaccinate due to safety concerns, especially those from lower-income backgrounds, who would face greater pressure to act contrarily to their beliefs. Additionally, preventing children from attending school was felt to misplace penalties for non-vaccination.
Health visitors felt that increased vaccination rates could not justify the ideological shift from current principles of empowerment and choice towards compulsion. Health visitors were also concerned that making MMR vaccination compulsory, where other child health decisions are subject to parental free choice, would introduce inconsistency to healthcare policy and practice, and overemphasise the importance of MMR relative to other vaccinations. Additionally, health visitors expected that non-voluntary vaccination would compromise parents' trust of, and willingness to seek help from, health visitors.
Two parents felt that the proposed schemes inappropriately positioned vaccination as a means to acquire financial benefits or secure a school place, and that protecting one's child against disease should solely motivate vaccination decisions.
Health visitors felt that existing data recording systems are too inefficient to support compulsory vaccination. One health visitor stated that she might refuse to cooperate with compulsory vaccination on conscientious grounds.
While our sample is not representative of parents who do not vaccinate their children, objections were raised consistently, regardless of child vaccination status. These findings suggest that compulsory or incentivised vaccination in the UK would meet with considerable opposition from parents and health professionals and so may not be feasible. Further work should address alternative options within a choice-based system before compulsory vaccination is considered.
Funding The study was funded by the National Social Marketing Centre, UK. The funder contributed to the design of the study but was not involved in interpreting findings or drafting the manuscript.
Competing interests None.
Ethics approval Ethical approval for focus groups with parents was granted by the University College London Psychology Department Ethics Committee (STF/2007/8/007). Clearance for interviews with health visitors was given by an NHS Research Ethics Committee (08/H0716/22).
Provenance and peer review Not commissioned; externally peer reviewed.
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