PztbL "H/th,Lond. (1979) 93, 11-15
Professional Attitudes Towards Vaccination and Immunization Within the Leeds Area HealthAuthoriW (Teaching) Peter Wilkinson S.R.N., N,D.N.CeTt., H.V,, Dip. Health Ed.. F.E.T.C., M.I.H.E.
Area Health Education Officer Lesley Tylden- Pattenson M.Sc.. D,H.S.A.
Health Education Officer and Judith Gould B.A., Cert. Ed.
Project Officer Leeds Area Health Authoritv (Teaching), Bond Court, Leeds The attitudes.of 333 General Practitioners, 22 Clinic Doctors, and I 16 Health Visitors within the Leeds Area Health Authority (Teaching) towards immunization were investigated. It was found that diphtheria, tetanus and polio immunizations were given routinely by 99 Yo of the General Practitioners and Clinic Doctors, and encouraged by 98 ~/~of all professionals. Measles prevention was given routinely by 86 ~o of General Practitioners and by all but one of the Clinic Doctors, and encouraged by 82 ~ of all professionals. The majority of General Practitioners (83 ~) and all but one of the Clinic Doctors gave immunization against pertussis as a matter of course. However, not all General Practitioners, Clinic Doctors or Health Visitors actively encouraged immunization against pertussis. This was probably because they were unsure whether tile advantages of giving pertussis vaccine outweighed the disadvantages. A decrease in uptake of the primary immunization schedule over a four year period was noticed 'by 34 ~ of General Practitioners and 43 ~ of Clinic Doctors and Health Visitors. Eightyeight per.cent of Clinic Doctors and Health Visitors and 83 ~ of General Practitioners had noticed increased concern among parents about immunization.
Introduction Early in 1974 there was widespread publicity concerning adverse reactions to pertussis vaccine. The number of children being immunized against pertussis, and to a lesser .extent diphtheria, tetanus and polio, was thought to have declined. Research was carried out by the Public Health Laboratory Service and others into the severity of pertussis, effectiveness of the vaccine, and the incidence o f complications; however, medical opinion about the desirability o f administering pertussis vaccine remained divided. In June 1974, the Department of Health and Social Security issued a statement recommending that immunization against pertussis should still be given as part of the primary immunization schedule, provid0038-3506/79/010011 +05 S01.00/0
© 1979 The Society of Community Medicine
12
P. H:ilkh~son e! aL
ing there were no contraindications, adding that if parents objected to tile triple vaccine (diphtheria, tetanus and pertussis), the diphtheria and tetanus components ,should be used, together with the polio vaccine. Within the Leeds Area Health Authority (Teaching), there has been a decline in acceptance of about 25 7/0for pertussis x,accine, although national figures show an overall decline in immunization take up since 1974. Current levels in the Leeds Area Health Authority (Teaching) for children born in 1975 are 77°//o for diphtheria, tetanus and polio, and 45% for pertussis. An advisory panel o n "Immunization and the Control of Infection" was formed within the Area Health Authority in 1976, and it was decided that its suggestion of a vaccination and immunization campaign should be implemented by the Health Education Service. To facilitate a decision on the content of the programme, a survey of professional attitudes towards immunization was carried out.
Methodology In November 1976 a questionnaire and explanatory letter were sent to all General Practitioners, Health Visitors and Clinic Doctors within the Leeds Area Health Authority (Teaching). The numbers distributed, returned and analyzed a~'e shown in Table 1. TABLE 1 General Practitioners Questionnaires distributed Questionnaires returned Questionnaires analysed
540 334 333
Health Visilors
Clinic Doctors
,!65 116 I 16
50 23 22
The two questionnaires which were not analysed were incomplete. Results for General Practitioners were analysed separately. Clinic Doctors were included with Health Visitors as their number was small, and the answers they gave to "open-ended" questions corresponded more closely with those of the Health Visitors.
Results Ninety-:nine per cent o f General Practitioners and Clinic Doctors gave immunization against diphtheria, tetanus and polio as a matter of course (the remaining I ~ did not give immunization routinely). Nearly all respondents actively encouraged parents to have their children immunized. They also considered prevention of these diseases to be important, (see .Tables 2 and 3) and that the advantages o f immunization outweigh any risks of adverse reaction. The prevention of pertussis and measles .was considered to be less important, and the major part of the report is concerned with attitudes towards immunization against pertussis. Attitudes towards measles prevention are mentioned briefly towards the end of the report. One hundred and fifty-eight (47 ~o) General Practitioners and 70 (51 ~) Health Visitors and Clinic Doctors thought it important to prevent pertussis and also believed that the adwantages of immunization outweigh the risks. One hundred and seventy-nine (54~) General Practitioners stated that they thought the advantages of immunization did outweigh the risks; this compares with 73 (53~o) Clinic Doctors and Health Visitors. O f these 179 General Practitioners, 172 gave immunization as a matter of course. Thirty-three (10%) General Practitioners felt that the advantages of immunization were not greater than the
13
Attitudes towards vaccination and #nmunization TAm.E 2. General Practitioner perceplion of ~he importance of immunization (Answers given as percentages--N= 333)
Diphlheria Polio Tetanus Pertussis Measles
No answer
No't important
Slightly important
important
Very important
0-5 0-5 0-5 2.0 0.0
0-5 0'5 0-0 3"5 9'0
2.0 0'0 2~0 20'5 22"5
5.0 1-0 6-5 24,0 21-0
92-0 98.0 91-0 50.0 47-5
TAm.v_ 3. Clinic Doctor/Health Visi¢or perception of the importance of immunization (Answers given as percentages--N= 138)
Diphtheria Polio Tetanus Pertussis Measles
No answer
Not important
Slightly important
Imporlant
VeD' important
2.0 2-0 2..,0 2"0 2-0
O'0 0-0 0-0 3-0 1-0
0"6 0-0 1,0 9-5 7.0
7.0 1-5 8.0 25-5 38-5
91.0 96-5 89.0 60"0 51.5
risks, although 13 of them nevertheless gave immunization routinely. This appears contradictorY, but it may be lhat they comply with t~heDepartment o f Health and Social Security policy rather than acting upon their own personal views. Forty-eight (14 ~) General Practitioners did not give pertussis vaccine as a matter &course. Of these 48, 28 felt that it was not important, or only slightly so, to prevent pertussis, and only 11 marked "very important" on the scale. O f the 275 (83 ~ ) who did give the vaccine as a matter of course, 51 felt it was not important, or only slightly so, to prevent pertussis, with 151 belie¥ing it to be "very important". Overall, 275 (83 ~ ) of the General Practitioners and all but one Clinic Doctor gave pertussis immunization in the absence o f recognized contraindications. Several questions were asked in t~rder to determine .the extent o f any influence medical personnel may have on parental attitudes towards pertussis immunization. Doctors and Health Visitors may offer information about the pros and cons of immunization either on their own initiative or in response to parental request. Doctors May refuse to administer the pertussis element of the immunization schedule, or give the vaccine routinely .to children whose parents have co.nsented, without having discussed it further with them. Two hundred and eleven (63 ~) General Practitioners encouraged parents to have their children immunized against pertussis, 105 (32 ~o) did not, and 17 (5 ~) did not answer. Of the Clinic Doctors and Health Visitors, 95 (69 ~) actively encouraged parents to have their children immunized, 33 (24~o) did not, and 10 (7~) did not answer. O f t h e 211 General Practitioners who actively encouraged immunization, 206 gave immunization as a matter of course. Overall, 11 (3 Yo)General Practitioners discouraged immunizationagainst pertussis. Of these, eight did not give vaccine routinely, two did, and one did not answer. None of the Health Visitors or Clinic Doctors actively discouraged pertussis immunization. Table 4 shows the changes in primary immunization uptake during the preceding four years as noticed by all medical personnel. Although 173 (52 ~ ) General Practitioners had noticed no change in uptake, 1:12 (34~) had noticed a decrease during this period. This compares with 30 ~ and 43 ~ in these categories for Clinic Doctors/Health Visitors. The large
14
P. Wilkinson e.t al.
TABLE4. Change in primary immunizalion uptake during'the preceding four )'ears as experienced by medical personnel General Health v~sitors.p,lus Practitioners ClinicDoctors Decrease No change Increase No answer Totals
l I2(34~)
t 73(52 ~) 24(7 ~) 24(7~) 333
60(43 ~) 41 (30 .%) 7(5 ~) 30(22%) 138
Health Visitors 46 35 7 28 116
Clinic Doctors 14 6 0 2 22
number o f Health Visitors not replying to this question probably felt that since it referred to "'your practice", it was not applicable to them. Two hundred and eighty-three (83 ~ ) General Practitioners had noticed an increased concern about immunization among parents during the four year period, 48 ( i 4 ~o) had not, and the remaining eight did not answer this question. One hundred and one (87 ~ ) H e a l t h Visitors and all but one Clinic Doctor bad noticed an increase in parental concern during the same period. Respondents were invited to state their views on the reason for any increase in concern. Most felt that the main contributory' factor was publicity given to adverse reactions to immunization, 49 stating that they felt this publicity to be "irresponsible", "'ill-controlled" or "biased", and a few singled out Members o f Parliament for special criticism. It was felt that the Department o f Health and Social Security should mou'~at a media campaign to remedy this position. Thirty-six General Practitioners had noticed increased concern about the potential adverse effects of the pertussis vaccine in particular. Eleven General Practitioners and one of the Clinic Doctors felt that fear o f these effects had led to decreased acceptance o f other immunizations. A further 12 General Practitioners recorded that parents were no longer aware o f the severity o f the group of infectious diseases covered by the primary immunization schedule, and the consequent need for protection against them. There was also felt to be a lack o f liaison between the Department o f Health and Social Security and General Practitioners, and a lack of official policy and direction regarding immunization against pertussis. A small number o f General Practitioners said that they felt personally responsible for side-effects, although they realized that pertussis vaccination was part of recommended policy. A large number o f those surveyed responded to an invitation to make any other comments, often making more than one comment. Twenty-two expressed criticism of, or reservations about, the use o f the computer. The chiefcomplaint here appeared to be that doctors can no longer pers~nally supervi:se patient's immunizationschedules. In contrast, 10 General Practitioners felt that Ihe use o f the computer and/or the Health Visitor attached to the practice had helped to b o o s t immunization uptake.
Measles Two hundred and twenty-seven (68 ~ ) General Practitioners and 124 (90 ~ ) other respondents placed prevention at the positive e n d o f the scale. Two hundred and eighty-five (86 ~ ) General Practitioners and all but one o f the Clinic Doctors immunized routinely. Two hundred and forty-two General Practitioners (73 ~o) and 104 (75~o) other staff.felt that the advantages outweighed the risks. Twelve General Practitioners ( 4 ~ ) actively discouraged immunization, whereas none ,of the Clinic Doctors did so.
Attitudes towards vacchtation attd bnmunization
15
Discussion Concern within the Leeds Area Health Authority (Teaching) about decreased levels .c~f immunization uptake, and therefore a lowering o f the "herd" immunity, was the primary motivating force behind this and an earlier study of parental attitudes towards immunization. Provisional computer dala had indicaled that there was a 51% t~ptake of diphtheria, tetanus and polio vaccination, and that the level for pertussis was only 30 ~, but as the survey progressed, more accurate information became available which showed that there was in fact a 73 % uptake for diphtheria, tetanus and polio, and a 41 ~ uptake for pertussis in 1974. In the light of these revised figures it seemed unlikely that the attitudes of personnel most closely concerned with the immunization procedure--General Practitioners, Clinic Doctors and Health Visitors--were contributing to parental reluctance to have their children immunized. Indeed, e×amination of the results of the survey showed that a substantial number of medical personnel felt that immunization, including that against pertussis, was important, and that they also made positive efforts to encourage parents to have their children immunized. Many respondents, however, were still doubtful about the value of pertussis immunization, and because this doubt was prevalent nationwide, in parents as well as professionals, a two year National Childhood Eneephalopathy Study was instituted in July 1976. It is hoped that at the end of this two-year period some definite conclusions will emerge as to the precise frequency and severity of complications of immunization against pertussis. In the meantime, current policy is still to encourage parents to take advantage of the full range of protection offered by the primary immunization schedule, and for.personnel to administer this routinely in the absence of recognized contraindications. If parents are unwilling to accept pertussis vaccine, then the diphtheria,, tetanus and polio elements should still be recommended. Despite the revised uptake figures being higher than was originally thought, it was decided to proceed with a campaign within the Authority to boost immunization, since it was felt that there was still a need .for improvement. Leaflets and posters were provided for Health Centres, Clinics, Pre-School Playgroups, Nurseries, Libraries etc. A mobile Health Education unit with display facilities was positioned in the City Centre, with staff in attendance, and •lapel stickers and leaflets were issued to passers-by. Poster panel.s were displayed in public transport, and publicity was given by the local press and radio. There were also several freestanding displays in circulation in Health Centres and Hospitals. Since the campaign, the uptake figures have increased to 77 ~ for d!phtheria, tetanus and polio, and 45 % for,pertussis (children born in 1975). The campaign is felt to have helped in some measure towards this .increase. To enable a picture to be obtained of the levels o f immunization uptake within the Loeds Area Health Authority, "Area Profile" maps have recently been produced, These give a breakdown of immunization uptake of children born in 1974 and 1975, plotted against the surgery location of their General Practitioner. Study o f these maps should indicate those parts of the Area in which uptake levels are unacceptably low, thus enabling high ,intensity campai;gns to be mounted within specific locations.
Acknowledgements We wish to thank Malcolm Kirby, Kay Waxbrick, Anne Hardy and the rest of the Health Education Service staff, past and present, and John Webster of .Leeds Polytechnic for their invaluable help with this survey.
Professional Attitudes Towards Vaccination and Immunization Within the Leeds Area HealthAuthoriW (Teaching) Peter Wilkinson S.R.N., N,D.N.CeTt., H.V,, Dip. Health Ed.. F.E.T.C., M.I.H.E.
Area Health Education Officer Lesley Tylden- Pattenson M.Sc.. D,H.S.A.
Health Education Officer and Judith Gould B.A., Cert. Ed.
Project Officer Leeds Area Health Authoritv (Teaching), Bond Court, Leeds The attitudes.of 333 General Practitioners, 22 Clinic Doctors, and I 16 Health Visitors within the Leeds Area Health Authority (Teaching) towards immunization were investigated. It was found that diphtheria, tetanus and polio immunizations were given routinely by 99 Yo of the General Practitioners and Clinic Doctors, and encouraged by 98 ~/~of all professionals. Measles prevention was given routinely by 86 ~o of General Practitioners and by all but one of the Clinic Doctors, and encouraged by 82 ~ of all professionals. The majority of General Practitioners (83 ~) and all but one of the Clinic Doctors gave immunization against pertussis as a matter of course. However, not all General Practitioners, Clinic Doctors or Health Visitors actively encouraged immunization against pertussis. This was probably because they were unsure whether tile advantages of giving pertussis vaccine outweighed the disadvantages. A decrease in uptake of the primary immunization schedule over a four year period was noticed 'by 34 ~ of General Practitioners and 43 ~ of Clinic Doctors and Health Visitors. Eightyeight per.cent of Clinic Doctors and Health Visitors and 83 ~ of General Practitioners had noticed increased concern among parents about immunization.
Introduction Early in 1974 there was widespread publicity concerning adverse reactions to pertussis vaccine. The number of children being immunized against pertussis, and to a lesser .extent diphtheria, tetanus and polio, was thought to have declined. Research was carried out by the Public Health Laboratory Service and others into the severity of pertussis, effectiveness of the vaccine, and the incidence o f complications; however, medical opinion about the desirability o f administering pertussis vaccine remained divided. In June 1974, the Department of Health and Social Security issued a statement recommending that immunization against pertussis should still be given as part of the primary immunization schedule, provid0038-3506/79/010011 +05 S01.00/0
© 1979 The Society of Community Medicine
12
P. H:ilkh~son e! aL
ing there were no contraindications, adding that if parents objected to tile triple vaccine (diphtheria, tetanus and pertussis), the diphtheria and tetanus components ,should be used, together with the polio vaccine. Within the Leeds Area Health Authority (Teaching), there has been a decline in acceptance of about 25 7/0for pertussis x,accine, although national figures show an overall decline in immunization take up since 1974. Current levels in the Leeds Area Health Authority (Teaching) for children born in 1975 are 77°//o for diphtheria, tetanus and polio, and 45% for pertussis. An advisory panel o n "Immunization and the Control of Infection" was formed within the Area Health Authority in 1976, and it was decided that its suggestion of a vaccination and immunization campaign should be implemented by the Health Education Service. To facilitate a decision on the content of the programme, a survey of professional attitudes towards immunization was carried out.
Methodology In November 1976 a questionnaire and explanatory letter were sent to all General Practitioners, Health Visitors and Clinic Doctors within the Leeds Area Health Authority (Teaching). The numbers distributed, returned and analyzed a~'e shown in Table 1. TABLE 1 General Practitioners Questionnaires distributed Questionnaires returned Questionnaires analysed
540 334 333
Health Visilors
Clinic Doctors
,!65 116 I 16
50 23 22
The two questionnaires which were not analysed were incomplete. Results for General Practitioners were analysed separately. Clinic Doctors were included with Health Visitors as their number was small, and the answers they gave to "open-ended" questions corresponded more closely with those of the Health Visitors.
Results Ninety-:nine per cent o f General Practitioners and Clinic Doctors gave immunization against diphtheria, tetanus and polio as a matter of course (the remaining I ~ did not give immunization routinely). Nearly all respondents actively encouraged parents to have their children immunized. They also considered prevention of these diseases to be important, (see .Tables 2 and 3) and that the advantages o f immunization outweigh any risks of adverse reaction. The prevention of pertussis and measles .was considered to be less important, and the major part of the report is concerned with attitudes towards immunization against pertussis. Attitudes towards measles prevention are mentioned briefly towards the end of the report. One hundred and fifty-eight (47 ~o) General Practitioners and 70 (51 ~) Health Visitors and Clinic Doctors thought it important to prevent pertussis and also believed that the adwantages of immunization outweigh the risks. One hundred and seventy-nine (54~) General Practitioners stated that they thought the advantages of immunization did outweigh the risks; this compares with 73 (53~o) Clinic Doctors and Health Visitors. O f these 179 General Practitioners, 172 gave immunization as a matter of course. Thirty-three (10%) General Practitioners felt that the advantages of immunization were not greater than the
13
Attitudes towards vaccination and #nmunization TAm.E 2. General Practitioner perceplion of ~he importance of immunization (Answers given as percentages--N= 333)
Diphlheria Polio Tetanus Pertussis Measles
No answer
No't important
Slightly important
important
Very important
0-5 0-5 0-5 2.0 0.0
0-5 0'5 0-0 3"5 9'0
2.0 0'0 2~0 20'5 22"5
5.0 1-0 6-5 24,0 21-0
92-0 98.0 91-0 50.0 47-5
TAm.v_ 3. Clinic Doctor/Health Visi¢or perception of the importance of immunization (Answers given as percentages--N= 138)
Diphtheria Polio Tetanus Pertussis Measles
No answer
Not important
Slightly important
Imporlant
VeD' important
2.0 2-0 2..,0 2"0 2-0
O'0 0-0 0-0 3-0 1-0
0"6 0-0 1,0 9-5 7.0
7.0 1-5 8.0 25-5 38-5
91.0 96-5 89.0 60"0 51.5
risks, although 13 of them nevertheless gave immunization routinely. This appears contradictorY, but it may be lhat they comply with t~heDepartment o f Health and Social Security policy rather than acting upon their own personal views. Forty-eight (14 ~) General Practitioners did not give pertussis vaccine as a matter &course. Of these 48, 28 felt that it was not important, or only slightly so, to prevent pertussis, and only 11 marked "very important" on the scale. O f the 275 (83 ~ ) who did give the vaccine as a matter of course, 51 felt it was not important, or only slightly so, to prevent pertussis, with 151 belie¥ing it to be "very important". Overall, 275 (83 ~ ) of the General Practitioners and all but one Clinic Doctor gave pertussis immunization in the absence o f recognized contraindications. Several questions were asked in t~rder to determine .the extent o f any influence medical personnel may have on parental attitudes towards pertussis immunization. Doctors and Health Visitors may offer information about the pros and cons of immunization either on their own initiative or in response to parental request. Doctors May refuse to administer the pertussis element of the immunization schedule, or give the vaccine routinely .to children whose parents have co.nsented, without having discussed it further with them. Two hundred and eleven (63 ~) General Practitioners encouraged parents to have their children immunized against pertussis, 105 (32 ~o) did not, and 17 (5 ~) did not answer. Of the Clinic Doctors and Health Visitors, 95 (69 ~) actively encouraged parents to have their children immunized, 33 (24~o) did not, and 10 (7~) did not answer. O f t h e 211 General Practitioners who actively encouraged immunization, 206 gave immunization as a matter of course. Overall, 11 (3 Yo)General Practitioners discouraged immunizationagainst pertussis. Of these, eight did not give vaccine routinely, two did, and one did not answer. None of the Health Visitors or Clinic Doctors actively discouraged pertussis immunization. Table 4 shows the changes in primary immunization uptake during the preceding four years as noticed by all medical personnel. Although 173 (52 ~ ) General Practitioners had noticed no change in uptake, 1:12 (34~) had noticed a decrease during this period. This compares with 30 ~ and 43 ~ in these categories for Clinic Doctors/Health Visitors. The large
14
P. Wilkinson e.t al.
TABLE4. Change in primary immunizalion uptake during'the preceding four )'ears as experienced by medical personnel General Health v~sitors.p,lus Practitioners ClinicDoctors Decrease No change Increase No answer Totals
l I2(34~)
t 73(52 ~) 24(7 ~) 24(7~) 333
60(43 ~) 41 (30 .%) 7(5 ~) 30(22%) 138
Health Visitors 46 35 7 28 116
Clinic Doctors 14 6 0 2 22
number o f Health Visitors not replying to this question probably felt that since it referred to "'your practice", it was not applicable to them. Two hundred and eighty-three (83 ~ ) General Practitioners had noticed an increased concern about immunization among parents during the four year period, 48 ( i 4 ~o) had not, and the remaining eight did not answer this question. One hundred and one (87 ~ ) H e a l t h Visitors and all but one Clinic Doctor bad noticed an increase in parental concern during the same period. Respondents were invited to state their views on the reason for any increase in concern. Most felt that the main contributory' factor was publicity given to adverse reactions to immunization, 49 stating that they felt this publicity to be "irresponsible", "'ill-controlled" or "biased", and a few singled out Members o f Parliament for special criticism. It was felt that the Department o f Health and Social Security should mou'~at a media campaign to remedy this position. Thirty-six General Practitioners had noticed increased concern about the potential adverse effects of the pertussis vaccine in particular. Eleven General Practitioners and one of the Clinic Doctors felt that fear o f these effects had led to decreased acceptance o f other immunizations. A further 12 General Practitioners recorded that parents were no longer aware o f the severity o f the group of infectious diseases covered by the primary immunization schedule, and the consequent need for protection against them. There was also felt to be a lack o f liaison between the Department o f Health and Social Security and General Practitioners, and a lack of official policy and direction regarding immunization against pertussis. A small number o f General Practitioners said that they felt personally responsible for side-effects, although they realized that pertussis vaccination was part of recommended policy. A large number o f those surveyed responded to an invitation to make any other comments, often making more than one comment. Twenty-two expressed criticism of, or reservations about, the use o f the computer. The chiefcomplaint here appeared to be that doctors can no longer pers~nally supervi:se patient's immunizationschedules. In contrast, 10 General Practitioners felt that Ihe use o f the computer and/or the Health Visitor attached to the practice had helped to b o o s t immunization uptake.
Measles Two hundred and twenty-seven (68 ~ ) General Practitioners and 124 (90 ~ ) other respondents placed prevention at the positive e n d o f the scale. Two hundred and eighty-five (86 ~ ) General Practitioners and all but one o f the Clinic Doctors immunized routinely. Two hundred and forty-two General Practitioners (73 ~o) and 104 (75~o) other staff.felt that the advantages outweighed the risks. Twelve General Practitioners ( 4 ~ ) actively discouraged immunization, whereas none ,of the Clinic Doctors did so.
Attitudes towards vacchtation attd bnmunization
15
Discussion Concern within the Leeds Area Health Authority (Teaching) about decreased levels .c~f immunization uptake, and therefore a lowering o f the "herd" immunity, was the primary motivating force behind this and an earlier study of parental attitudes towards immunization. Provisional computer dala had indicaled that there was a 51% t~ptake of diphtheria, tetanus and polio vaccination, and that the level for pertussis was only 30 ~, but as the survey progressed, more accurate information became available which showed that there was in fact a 73 % uptake for diphtheria, tetanus and polio, and a 41 ~ uptake for pertussis in 1974. In the light of these revised figures it seemed unlikely that the attitudes of personnel most closely concerned with the immunization procedure--General Practitioners, Clinic Doctors and Health Visitors--were contributing to parental reluctance to have their children immunized. Indeed, e×amination of the results of the survey showed that a substantial number of medical personnel felt that immunization, including that against pertussis, was important, and that they also made positive efforts to encourage parents to have their children immunized. Many respondents, however, were still doubtful about the value of pertussis immunization, and because this doubt was prevalent nationwide, in parents as well as professionals, a two year National Childhood Eneephalopathy Study was instituted in July 1976. It is hoped that at the end of this two-year period some definite conclusions will emerge as to the precise frequency and severity of complications of immunization against pertussis. In the meantime, current policy is still to encourage parents to take advantage of the full range of protection offered by the primary immunization schedule, and for.personnel to administer this routinely in the absence of recognized contraindications. If parents are unwilling to accept pertussis vaccine, then the diphtheria,, tetanus and polio elements should still be recommended. Despite the revised uptake figures being higher than was originally thought, it was decided to proceed with a campaign within the Authority to boost immunization, since it was felt that there was still a need .for improvement. Leaflets and posters were provided for Health Centres, Clinics, Pre-School Playgroups, Nurseries, Libraries etc. A mobile Health Education unit with display facilities was positioned in the City Centre, with staff in attendance, and •lapel stickers and leaflets were issued to passers-by. Poster panel.s were displayed in public transport, and publicity was given by the local press and radio. There were also several freestanding displays in circulation in Health Centres and Hospitals. Since the campaign, the uptake figures have increased to 77 ~ for d!phtheria, tetanus and polio, and 45 % for,pertussis (children born in 1975). The campaign is felt to have helped in some measure towards this .increase. To enable a picture to be obtained of the levels o f immunization uptake within the Loeds Area Health Authority, "Area Profile" maps have recently been produced, These give a breakdown of immunization uptake of children born in 1974 and 1975, plotted against the surgery location of their General Practitioner. Study o f these maps should indicate those parts of the Area in which uptake levels are unacceptably low, thus enabling high ,intensity campai;gns to be mounted within specific locations.
Acknowledgements We wish to thank Malcolm Kirby, Kay Waxbrick, Anne Hardy and the rest of the Health Education Service staff, past and present, and John Webster of .Leeds Polytechnic for their invaluable help with this survey.
