Acceptability of universal hepatitis B vaccination among school pupils and parents

Transcription

1 Acceptability of universal hepatitis B vaccination among school pupils and parents A Hinds, JC Cameron Summary: The World Health Organisation (WHO) recommends universal hepatitis B (hepb) vaccination for all countries, but this policy has not been adopted in the UK and its acceptability there is unknown. We investigated the attitudes of secondary one (S1) school pupils aged years (n = 50) and parents (n = 39) using semi-structured focus group discussions. There was a lack of awareness of hepb among most participants prior to the study. Parents sought further information, including the risks of infection and vaccine side effects. No participants identified cultural or socioeconomic barriers to being vaccinated against hepb. The majority of pupils and nearly all parents were in favour of universal hepb vaccination. Offering hepb vaccination to all S1 pupils, in school, should therefore be highly acceptable, providing that sufficient information on the risk of hepb infection and vaccine safety is provided. A facility for answering questions and a forum for pupil education should also be offered. Key words: adolescence attitudes hepatitis B knowledge parents practice pupils vaccines Commun Dis Public Health 2004; 7(4): Introduction WHO has recommended that all countries introduce universal hepatitis B (hepb) vaccination of infants and/ or adolescents, regardless of the national prevalence of infection 1. This strategy has been implemented in at least 151 countries 2,3, but not in the UK where hepb vaccination is restricted to high-risk populations 4-6. Possible reasons why the universal policy has not been adopted in the UK include current low incidence, equivocal cost-effectiveness analyses and a belief that high levels of coverage would be difficult to achieve 5-9. It has been suggested that some parents would feel that their child would not engage in high-risk behaviours, such as unprotected sexual intercourse and injecting drug use, and therefore they would not give consent for vaccination 8. However, no studies investigating the acceptability of hepb vaccination in the UK have been published and uptake rates of over 90% have been A Hinds Centre for Health and Social Research, Fife JC Cameron Health Protection Scotland, Glasgow Address for correspondence: Dr J Claire Cameron Health Protection Scotland Clifton House Clifton Place Glasgow G3 7LN tel: fax: claire.cameron@hps.scot.nhs.uk achieved in some countries where adolescent immunisation has been undertaken 3, We therefore investigated the attitudes of school pupils and parents toward universal adolescent hepb vaccination. This was in the context of planning to offer hepb vaccination to all secondary one (S1) pupils in Glasgow the following year. The results obtained were therefore not hypothetical, but key to informing this pilot project, the first of its kind in the UK. Methods Design Focus groups were used to investigate the knowledge, attitudes and acceptability of hepb vaccination 13. Participants and setting Four secondary schools in Greater Glasgow were invited to participate. These schools were selected to reflect as closely as possible the broad range of socio-economic, religious and ethnic groups across the area (table 1). Recruitment Each school was asked to invite S1 pupils, aged years, and parents of S1 pupils to attend focus groups during May and June Pupils Invitations were issued to one non-streamed Personal and Social Education (PSE) class at three schools (average 28 pupils/class). Two pupils were selected from each of the streamed registration classes at the fourth school (25 pupils/class). Once sufficient pupils had agreed to participate, teachers were asked draw a sample of VOL 7 NO 4 DECEMBER 2004

2 TABLE 1 School characteristics by deprivation category, religious status and ethnic mix School Deprivation category* Religious status Ethnic mix A High Roman Catholic 97% Caucasian B High Nondenominational 61% Caucasian C High Nondenominational 98% Caucasian D Low Nondenominational 79% Caucasian original reports * A deprivation category for the school was derived from the Carstairs score, based on postcode sector of residence for the S1 (secondary one) year group ( ). The deprivation scores were based on the 1991 census: Low (Carstairs 1-3); Medium (Carstairs 4-5); High (Carstairs 6-7). 14 pupils at random, with an equal number of males and females where possible. Parents Head teachers sent invitations to all parents/guardians of S1 pupils. Where necessary, to obtain 8-12 participants, a second wave of invitations was issued. HepB Information sheet An information sheet was developed (appendix 1), which was given to participants approximately one week prior to discussions. Data collection Topic guides for discussions were developed, and included open questions to explore participants views on vaccinations, bloodborne viruses, hepb information provided, the idea of universal hepb vaccination and reasons for participation/nonparticipation. Focus groups with pupils at each school were held during school hours, usually as part of a PSE class. The parent groups were held on school premises in the early evening of the same day. All parents were offered 10 to cover travel and any other expenses incurred as a consequence of participating in the group. Nine focus groups were held, five with pupils and four with parents. A second pupil group was held at school B, as attendance at the first session was poor (four pupils). A total of 50 pupils and 39 parents participated (table 2). The focus groups were facilitated by one researcher (AH), who used the topic guides as consistent prompts for participants to express their own thoughts and opinions. The discussions were tape recorded and a scribe took notes. Tape recordings were transcribed verbatim and quality checked. Qualitative analysis The data collected were analysed manually using grounded theory 15. In the preliminary analysis interview transcripts were read repeatedly and the emergent themes were used to code sections of the text. Data were then delimited by a process of comparing and connecting themes so that relation-ships and resemblances between themes became core categories. Ethical approval Ethical approval was received from Greater Glasgow Community/Primary Care Local Research Ethics Committee. Written informed consent was obtained from both pupils and parents. Results The main themes to emerge from data are presented with quotations, selected because they are typical of respondent observations. Immunisation in general Although most pupils generally disliked vaccinations, they understood the importance of being protected. All parents who expressed an opinion were in favour of universal immunisation for other diseases. However, a number of parents felt that the possible side effects were not always disclosed and made particular reference to MMR. Parent: I m fully supportive of immunisation, I think I do feel though that sometimes we re not given all the facts and you know the negative sides are unsaid or are always, you know, implicit rather than explicit and I think that s always a concern really. The majority of pupils preferred having vaccinations at school rather than at a health centre because of peer support. Pupil: If you see all your friends having it you ll feel more confident. Many pupils also preferred not to be informed of vaccinations too far in advance, as this would make them more anxious. Most parents were in favour of school vaccination and felt that their children would prefer this. Lack of privacy and embarrassment were perceived as barriers to vaccination in school by a minority of pupils and parents. TABLE 2 School S1 pupils Parents of S1 pupils Male Female Male Female A B C D Total S1 = secondary one. Number and sex of focus group participants VOL 7 NO 4 DECEMBER

3 Hepatitis B Most pupils admitted to previously knowing little or nothing about hepb. Whilst a few parents were well informed due to their occupations or personal experience of friends or family having been infected, there was a general lack of awareness. Many of the pupils failed to understand that hepb transmission necessitated contact with infected body fluids. This led to the belief that body piercing, tattooing and sharing toothbrushes would auto-matically lead to hepb infection, which in turn generated some anxiety: Pupil: How can you get it because you know how it s in your liver, how can you get it if you pierce your ear? Many parents also displayed a lack of under-standing concerning the routes of hepb transmission, with some parents under the impression that it was only a risk for drug users: Parent: I thought it was just drug users that got it. Most pupils perceived that they could be at risk of becoming infected with hepb in the future and therefore required protection. The majority of parents were also concerned that their child could be at future risk. Parent: I mean we don t know how promiscuous our children are going to be or if they are going to be intravenous drug users or not. We would all hope that they wouldn t be but. Few pupils wished any other information about hepb, but a number of parents sought further information about the risk of infection, and its long-term consequences. parents felt strongly that they should be provided with information about any potential side effects of hepb vaccination and that they required further evidence of vaccine safety before they could decide as to whether their child should be vaccinated. They would also like more information on vaccine efficacy and duration of protection. Such information should be clear and evidence based. Parent: I would like to see the side effects first before I would sign anything. Some parents expressed the view that vaccination should be accompanied by a school education programme about transmission of hepb, possibly with the input of health professionals. Parent: I have a slight concern in if you start vaccinating them against it, they ll just forget it s out there there s got to be a lot more education as well. A few pupils and several parents would seek further advice about hepb vaccination from their GP or other health centre staff. Some parents would also acquire information from the internet or an infectious diseases unit. Additionally, a few parents expressed concern that vaccinating against hepb could provide some adolescents with a licence to indulge in high-risk behaviours: Parent: I still have a fear that there are other viruses out there and if they get this [vaccination] and they think right that s me protected from hepatitis, I don t need now to worry. Now I think it has to be made clear that they still do need to protect themselves it s not a go ahead to behave however you want to. Universal hepatitis B vaccination for school pupils A number of pupils and parents required further explanation as to why S1 pupils would be offered hepb vaccination, as they did not perceive them to be at immediate high risk. Parent: So if it s only done for people at high risk then why would they want to do it for children if they re not at high risk then? Most pupils felt it unfair that adolescents elsewhere were routinely vaccinated against hepb while those in the UK were not, but opinion amongst parents was divided. Whilst some parents perceived the UK to be lagging behind other countries, others felt that adopting a cautious attitude could be beneficial. Many pupils had not understood that hepb vaccination involved a series of three injections. Although the majority were unhappy about having more than one injection, few felt that this would be a barrier. The majority of parents felt pupils would agree to be immunised, albeit unwillingly in some cases. A few parents felt that greater emphasis of the importance of being protected against hepb would encourage their child to undergo a series of injections. When the possibility of receiving a newly developed hepb vaccine given as two rather than the current three doses was raised, the majority of pupils did not feel that this would influence their decision to be vaccinated. However, there was a mixed response from parents, with some expressing suspicion that there may be less safety data for a newer vaccine. Many Decision for hepb vaccination Most pupils would wish to discuss vaccination with their parents or main carer, should it be offered. There was a difference of opinion concerning who would make the decision to be vaccinated or not: some pupils felt strongly that this should be their decision whilst others would have to abide by their parents wishes. Most parents would want their children to have the opportunity to discuss the issues raised about hepb in any health education material provided, although opinion was divided as to whether the most appropriate forum was at home or in school. The majority of pupils and nearly all parents were in favour of the introduction of hepb vaccination for S1 pupils: Pupil: we re better getting it [vaccination] when we re younger than regretting it when we re older. Parent: I mean, you know they re sort of safe if they do get the injection because as you know there s so many things going about, diseases and drugs and there is children that have sex, underage sex, you know, so I think it s a good idea. None of the pupils or parents identified any religious, cultural or socioeconomic barriers to being vaccinated against hepb. Discussion Although there was a general lack of awareness about hepb, the majority of pupils and nearly all parents were in favour introducing universal hepb vaccination. This suggests that it would be a highly acceptable public health intervention. 280 VOL 7 NO 4 DECEMBER 2004

4 The study was conducted in Glasgow, but it is probable that it represents the UK as a whole, as schools were selected to reflect as broad a range of socioeconomic, religious and ethnic groups as possible. There was a disproportionate number of females participating in the parent groups (36 females versus three males), but this is likely to reflect general availability and responsibility for child health matters within the family. Although there are no similar published studies for the UK, the results obtained mirror those from other countries prior to the introduction of universal vaccination. For example, in the US, adolescents and parents were also found to have little existent knowledge about hepb or risk of infection 16,17 and it was noted that educational strategies to increase this knowledge base would be essential for successful routine vaccination. In our study, pupils and parents seemed more concerned about pupils future risk of acquiring hepb than in these other studies. It is possible that they may have overestimated the risk of being infected through activities such as tattooing or skin piercing, both of which have recently become very popular among adolescents in the UK. However, both pupils and parents still supported universal vaccination even when the relatively low risk from these activities, and the high risk from unprotected sexual intercourse and injecting drug use was outlined. Key practical recommendations that emerged are: Vaccination could be administered through schools, but consideration should be given to those who would prefer health centre vaccination. General public awareness of the risks of hepb infection, how the virus is transmitted and why protection via vaccination is important should be raised. Separate health education material for parents and pupils should be considered, with clear information about the routes and risks of hepb transmission, why hepb is administered as a series of injections, the long-term consequences of being infected, the possible side effects of hepb vaccination and duration of protection. Ways should be sought of providing a forum for discussion of hepb vaccination with pupils and answering any questions that may arise. The results of this study are important, as there has been no previous published investigation of attitudes towards the idea of a universal adolescent hepb vaccination programme in the UK. Such a programme might be implemented in the future, and hepb policy is under review by the Joint Committee on Vaccination and Immunisation. The results may also provide a starting point to inform strategies for the possible use of vaccines against other sexually transmitted infections, such as human papilloma virus (HPV) and Herpes simplex virus, which are both at advanced stages of development. Since study completion, the results have been used to inform a pilot programme in Greater Glasgow, in which hepb vaccination was offered to all 11,000 S1 pupils. The high uptake rates achieved in practice further confirm the validity of the positive results obtained in this qualitative study 18. Acknowledgements We would like to thank all those who contributed to this study, at Health Protection Scotland (formerly Scottish Centre for Infection and Environmental Health), the former Centre for Health and Social Research, Greater Glasgow NHS Board, the Schools Health Service of Yorkhill NHS Trust and participating schools. Funding was provided by an educational grant from GlaxoSmithKline. Appendix 1 Hepatitis B a disease everyone could be protected against What is hepatitis B? Hepatitis B is virus that can cause serious liver disease and even death. People with recent hepb infection have: Yellowing of the skin or eyes, Extreme tiredness, loss of appetite, Feeling sick, vomiting, Fever, Pains in muscles, joints, or stomach. Some people are not ill when first infected, but the virus can stay in the body for a lifetime and cause ongoing liver damage including liver cancer. How can I get hepb? HepB is spread through coming into contact with an infected person s blood, or other body fluids. It can be spread by: Tattoos, ear piercing, or body piercing with unsterile equipment, Sexual intercourse, Contaminated needles, including accidental contact, Human bites, Sharing chewing gum, toothbrushes, razors, nailclippers etc, Bleeding wounds. How can I be protected from hepb? You can be protected by a series of 2 or 3 jags, given over a period of 4 to 6 months. The vaccine is very safe and effective. For nearly 20 years it has been used to protect people at high risk of hepb in the workplace (including nurses, doctors, lab staff, dentists) and travellers to high-risk countries. The vaccine does not contain live virus, and there is no possibility of becoming infected with hepatitis from it. No blood test is needed. Why give hepb vaccine to first year pupils? It is best to protect young people before they encounter the greatest risks. There is no way to predict who may be infected with hepb in the future everyone is at potential risk. HepB vaccine is already given to all school children in almost every other European country, USA, Canada and Australia. School pupils in the UK are not currently offered hepb vaccine. original reports VOL 7 NO 4 DECEMBER

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