Evid Based Nurs 5:122 doi:10.1136/ebn.5.4.122
  • Qualitative

Parents found it difficult to obtain objective information and advice about the combined mumps, measles, and rubella vaccine

    QUESTION: What factors influence parents’ decisions about whether to accept the combined measles, mumps, and rubella (MMR) immunisation for their children?


6 focus groups.


Avon and Gloucestershire, UK.


48 parents who were 22–48 years of age (mean age 35 y, 90% mothers). Parents had accepted (3 focus groups) or not accepted (3 focus groups) MMR immunisation for their youngest child (14 mo to 3 y of age).


A moderator facilitated each group and asked open ended questions about child health, attitudes towards immunisation, the decision making process, the effects of the media and other influences on immunisations, and issues that were important to parents. The 1–2 hour discussions were tape recorded and transcribed. The data were analysed using the constant comparative method until theoretical saturation was reached.

Main findings

4 key factors influenced parents’ decisions about MMR immunisation. Beliefs about the risks and benefits of immunisation compared with the risks associated with contracting measles, mumps, or rubella: immunisers tended to stress the benefits of immunisation and the dangers of the diseases, but they were still concerned about the MMR vaccine and its possible association with autism and bowel disorders. Parents expressed that it was important to develop their child’s natural immunity through exposure to mild infections. Non-immunisers perceived that vaccines placed stress on a child’s immature immune system, and they were less fearful of diseases in general. Many parents thought that 3 separate vaccines for measles, mumps, and rubella would be safer. Parents expressed confusion about the role of breast feeding in promoting immunity and did not understand why immunisation was also necessary. Responses to information from the media and other sources about vaccine safety: media publicity about the possible link between the MMR vaccine, autism, and Crohn’s disease raised doubts in parents who had not previously questioned the safety of immunisation. Although parents realised that media reports could be sensationalised, the Department of Health statements did not reassure them because they felt their concerns had not been adequately addressed. Parents obtained information from several sources to investigate the safety of MMR immunisation but felt much of the information was biased. Confidence and trust in the advice given by health professionals and attitudes towards compliance with medical recommendations: parents found it difficult to have an open discussion with health professionals. They felt pressured, and often it was just easier to comply than to refuse. Some parents were afraid to ask questions and be labelled as a nuisance. Parents also felt uncomfortable about general practitioners (GPs) receiving payments for achieving immunisation targets. They could not be sure that GPs were motivated solely by what was in the best interests of the child. Views on the importance of individual choice within government policy on immunisation: parents valued the ability to choose which, if any, immunisations their children would receive. They also wanted the options of single vaccines for measles, mumps, and rubella, and immunisation at an older age. They felt that the promotion of MMR immunisation was based on considerations of cost and convenience. Their main consideration was the health of their own child rather than the societal benefits of immunisation.


Parents found it difficult to get independent, objective, current information about the risks and benefits of the combined measles, mumps, and rubella (MMR) immunisation.


  1. Judi Daniels, RN
  1. MSN Board Certified Family Nurse Practitioner and Pediatric Nurse Practitioner  University of Kentucky College of Nursing, Lexington, Kentucky, USA

      Vaccine related issues are not exclusive to the UK. In the US, for example, concerns about the safety of vaccines were fuelled by reports of problems associated with the rotoshield vaccine, the oral polio vaccine, and the thimerasol preservative in the Hepatitis B vaccine.1,2 Parents are barraged with often conflicting information and may process this information without the benefit of critical appraisal skills to interpret the quality and meaning of the evidence. Evans et al elucidate why some parents in the UK chose to immunise despite negative media attention about the combined MMR vaccine. Parents’ concerns, although specific to the MMR vaccine, may reflect the distrust people have of the healthcare system in general.

      Evans et al, although using modified grounded theory, do not suggest potential theoretical propositions to explain their findings. A possible link between the identified themes may be the quality of the patient–provider relationship. Each theme included comments about providers being biased, intimidating, or not giving adequate information. These issues suggest the need for nurses to examine their own approaches to vaccinations and how information is given to parents. We must maintain an awareness of what parents are reading and address their concerns openly. Providers should examine their own philosophies on parent choice and how they are communicated to parents.

      Future research on the beliefs of healthcare providers about immunisations would offer potential strategies for specific interventions. This research, coupled with studies aimed at identifying why parents change their position on immunisations, would be helpful. Finally, research would enhance our understanding of how organised health care is used by non-immunisers; this group may need a different approach by providers.



      • Source of funding: NHS Executive South West Regional R&D Directorate.

      • For correspondence: Ms M Evans, University of Bristol, Bristol, UK. m.a.evans{at}

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