an average of 2.4 people for England and Wales. Of these 3,419 households a high percentage of these are privately owned (76.6%), just 7.8% are rented from the local authority (ONS 2001).
Goring has two main shopping parades and several small shops which serve the local community well. Goring also has a small trading estate, allowing the basic commercial needs of residents to be met whilst also providing job opportunities. Employment statistics for the area are quite good - of the economically active just 1.84% of Castles population are unemployed. Approximately half of the workforce of Castle travel a distance of less than 3 miles to their place of work.
The area is well served with local busses and trains, community transport is also available to those who require, providing links to neighbouring towns where more specific needs can be met. Statistics show that nearly a quater of households within Castle (23.2%) have no access to a private vehicle (ONS 2001), these residents therefore may be reliant on public transport.
Five schools can be found within the Goring region, serving primary, secondary and adult education, Goring also hosts several pre-school nurseries. There are also 2 day centres, a residential home and a respite home for people with learning disabilities. The number of dependent children within Castle Ward is 1,443, this equates to 18.28% of the population.
Leisure facilities for children and adults are well catered for with designated play areas for the younger children and a local leisure centre with many activities offered to appeal to all ages and fitness levels.
The A27 runs along the North of Goring, connecting it to the adjacent towns of Littlehampton and Worthing, access is also available to Worthing via the A259.
The nearest town, Worthing, which is the largest town in West Sussex, lies to the East of Goring, here there is a hospital specialising in many aspects of health care and which has a busy Accident and Emergency department. A smaller hospital is situated 9 miles away in Shoreham-by-Sea.
Health care is easily accessible in this area due to the vast amount of G.P surgeries and it appeared that the majority of the populations needs were being met. The majority of the residents of Castle Ward report their general health as ‘good’ with just 9.03% complaining of poor health, however 19.03% are reported to be living with a limiting long term illness (ONS 2001). Within Goring there are several chemists, chiropodists and dentists, all of which aim to support the general health of residents.
Health Need
The health need that has been identified in my placement area is the poor uptake of the MMR (Measles, Mumps and Rubella) vaccine, and the implications this can have on health. The recent outbreaks of Measles and Mumps and the general decline of uptake we have seen nationally is cause for concern that these childhood diseases will be re-emerging. The rationale for this Health Profile is the high rate of non-attendance for the MMR vaccine observed whilst on placement with the practice nurse.
Measles is one of the most contagious diseases known, it is an acute viral illness which can cause serious complications including blindness, encephalitis, severe diarrhoea (possibly leading to dehydration), ear infections and severe respiratory infections such as pneumonia, which is the most common cause of death associated with measles.
Mumps, is a viral infection primarily affecting the salivary glands. Although mostly a mild childhood disease, mumps virus may also affect adults, among whom complications such as meningitis and orchitis are relatively common. Encephalitis is a rare complications of mumps.
Rubella is normally a mild childhood disease. however, infection during early pregnancy may cause fetal death or congenital rubella syndrome (CRS); characterised by multiple defects, particularly to the brain, heart, eyes and ears.
Suffering, complications and death caused by measles, mumps and rubella can be easily prevented through immunisation, however for an immunisation programme to be effective there should be an uptake of 95% in each practice population in order to maintain an adequate herd immunity (WHO 2005b).
Following the introduction of the MMR vaccine in 1988, there was a considerable decrease in the notifications of measles, mumps and rubella. However for the children receiving just one dose of MMR only a 90% protection against measles and mumps was obtained and 95% for rubella (NHS 2004). A second dose of MMR was introduced to the immunisation shekel in 1996, adding a second dose increases the protection for all three diseases to over 99% (NHS 2004).
Although the number of notifications may be considered relatively small compared to national figures it is a concern that preventable diseases are still occurring in a developed country where preventative vaccines are readily available. Table 1 summarises notifications from 1999 to 2003 for Adur, Arun and Worthing and compares these to notifications for the same period in England and Wales.
Table 1 Source: Health protection Agency
A report published in The Lancet by Wakefield et al in 1998 claimed there was a link between the MMR vaccine and autism and inflammatory bowel disease (Fitzpatrick 2004). This soon lead to a loss of public confidence in the vaccination programme, as a result of this a steady decline in uptake of the vaccine has been seen nationally, regionally and locally (AAW 2005a) please see appendix 7.
Although the uptake in AAW continues to be above the regional average, a decline in recent years has been observed. The Health Care Commissions 2004 ratings shows that AAW PCT fell into Band 3 for MMR uptake with just 81% coverage. (Healthcare Commission 2004). Although the most recent performance ratings (2004/2005), have shown a slight increase of coverage of MMR to 85% compared to the national figure of 81%, this still places the trust in Band 4 for performance level (Healthcare Commission 2005), which suggests that there is still room for improvement.
The PCT annual report statistics show a variation in uptake rates across GP practices, these range from 64% with the highest practice achieving 95% (AAW 2005b). Table 2 below shows the number of eligible children aged 2 by April 2004 and their immunisation status.
Table 2 Source: West Sussex Child Health Bureau
The table clearly shows that the uptake of the MMR vaccine is well below the recommended rate, however the uptake rate for the Men C vaccine is in line with that recommended. This suggests that parents are willing to have their child vaccinated with vaccines that they deem to be safe, supporting research that there has been a loss of public confidence in the MMR immunisation programme.
Immunisation statistics for children resident in the district for the period covered 2003/04, who had reached their fifth birthday receiving the second dose of the MMR vaccine within my placement area are shown in following Table 3 below.
Table 3
Source: West Sussex Child Health Bureau
This health need is relevant to deprived and affluent areas alike. Previous studies have shown that those who remain unimmunised, or who are not fully up to date, are more likely to live in deprived areas and are less likely to access primary care services (Baker et al 1984), however more recent statistics seem to suggest the opposite. According to Atkinson et al (2004), coverage decreased Nationally by a greater proportion in affluent areas. From 1997 to 2001, MMR immunisation rates declined in all areas, although the decrease in affluent areas was slightly greater (by 5%) than in deprived areas which was 4.2% (Middleton et al 2003). Affluent populations are, in general, the first to take up practices which are perceived as protective to health and have therefore been considered to be the first to stop practices which may be damaging to health. There is some research to suggest that parents from affluent backgrounds are unwilling to have their child immunised with the triple vaccine, and attend private clinics for their child to receive single vaccines.
A study in Ireland showed differences in opinion on the MMR vaccination have been observed among social classes. Eleven percent of middle class people were against the vaccination compared to 6% in the lower socio-economic group (Houston 2002). The 24 to 34 year old age group were the most likely to list autism as their reason to not vaccinate. The reasons for not vaccinating their children are provided in appendix 8. Deprivation can also have an adverse effect on immunisation uptake, although Castle falls into the less deprived classification in the Jarman, Townsend and Breadline Britain indices, the Child Poverty Index and West Sussex Health Needs Index score the area as the most deprived (West Sussex Health Authority 2002).
Lack of transport is also known to be a barrier to immunisation uptake in some communities (DoH 2005), as a high percentage of the population of Castle do not have access to a private vehicle this may have influenced parents decisions not to attend appointments.
Other barriers to the uptake of immunisation which would also need to be considered include ethnic minority groups, children in care, children with learning disabilities, children not registered with a GP and children of vulnerable adults such as asylum seekers and the homeless (DoH 2005).
Health Promotion
Currently, written information is available in the doctors surgery (appendix 9), which was located within the reception area. Although available to those who sought the information I feel that it was not the prime location for health promotion leaflets. More information could have been placed within the waiting area of the surgery, where generally individuals have more time to browse the information available. I feel the surgery could also have provided more patient information boards, arranged by topics, i.e. one for child health related topics, as well as other relevant themes, perhaps even related to seasons.
As a result of the decline of immunisation statistics within the PCT, the West Sussex Immunisation and Vaccination Committee has been founded. The PCT has also formulated an action plan to tackle this issue and plans to send a press release to local papers urging parents to reconsider their decision in the light of recent evidence.
Additional training has also been put into place for practice nurses which aims to bring them up to date with the facts about MMR. Health visitors are also being encouraged to attend immunisation sessions as sources of advice to practice nurses and parents (AAW 2005a).
At present, parents are sent out an immunisation appointment for their child, if parents fail to attend this appointment they will be sent out a second appointment. Failure to attend this second appointment means that parents are then sent out a letter asking for them to contact the surgery to confirm that they are still residing at the recorded address, if parents do not respond to this request they risk being struck off the doctors book. Through my experience, many of the immunisation clinics held at the practice were during the midmorning period. Many parents often feel this time inconvenient due to other child care or work commitments they may have. A way of improving the uptake rates may be to send out a reminder that the child's vaccinations are due and inviting the parents/carers to phone the surgery to make a convenient appointment. If this fails, the parents could then be contacted by phone to see if they are willing to make an appointment.
It is also important to consider the importance of opportunistic immunisation. When a child attends the surgery for a regular appointment, health care professionals should check the child's immunisation status and the necessary vaccinations should be offered. Opportunistic immunisations could also be undertaken by Health Visitors who could check the immunisation status of the child while on home visits.
Although running clinics for a specific immunisation programme has several advantages, for example, the paper work can be and processed more efficiently and cost saving through the use of multidose vials there are also several disadvantages which may contribute to poor vaccination levels. Having a more relaxed approach to immunisation appointments, not only makes the process more flexible for parents with other commitments, but also makes the nurses job more interesting, as some nurses find running clinics repetitive to have a continuous flow of patients attending for the same reason (Ingram 1995).
Whilst on placement with the practice nurse, I attended a baby clinic with the Health Visitor. The clinic was run weekly in the local church hall. Although the clinic was extremely well organised in that it provided a welcoming and relaxed atmosphere, with seating arranged around play mats for the babies to encourage the parents to socialise with one another, it did not provide any information for parents and carers to take away with them. I feel that an information board relating to all child health issues would have been hugely beneficial within this environment. This would enable parents and carers to take information away to discuss with partners or other significant others.
To improve the uptake rates of immunisations I think it would be advantageous to encourage parents to start to consider having their baby vaccinated during pregnancy. Future parents are bombarded with literature throughout pregnancy with regards to the ‘Breast is Best’ campaign, although there is no mention of the current vaccination programme recommended by the Department of Health and World Health Organisation in any of the pregnancy books I have read. Highlighting the benefits of vaccinations early in pregnancy will enable parents and guardians time to seek support and advice from friends and health care professionals before making an informed decision regarding the welfare of their child.
Information leaflets could also be placed within the local chemists, where parents would be able to pick up a copy while waiting for prescriptions and would also be able to seek the professional advice from the pharmacist.
Conclusion
Although I have highlighted some of the issues which may influence the uptake of the MMR vaccination within the text, some of these need to be explored more thoroughly as there may be wider implications involved.
All practices need to strive to reach the 95% target required to achieve an adequate coverage to prevent the return of these potentially devastating childhood diseases.
Unfortunately rebuilding public confidence in the MMR vaccine will take time. There will continue to be an ongoing need for clear, accessible and accurate information for each cohort of new parents to enable them to make informed choices about MMR. It is vital that healthcare professionals have a sound knowledge of the facts of MMR so these can be conveyed to parents/carers.
Equally important is the need to continue a positive image through the use of effective campaigns and a more relaxed approach so a higher percentage of children can be opportunistically vaccinated. Healthcare professionals will need to work together in providing parents with accurate information and support parents in making these decisions if these targets are to be met.
References
Adur, Arun and Worthing. 2005a. AAW Teaching Primary Care Trust Board Meeting, 27th January 2005. Measles Mumps and Rubella Immunisation in AAW tPCT. West Sussex: AAW tPCT.
Adur, Arun and Worthing. 2005b. Living today with tomorrow in mind; the annual report of the director of public health 2004. West Sussex: RWP.
Atkinson, P., C. Cullinan., J. Jones., G. Fraser and H. Maguire. 2004. Large outbreak of measles in London: reversal of health inequalities. BMJ 90: 424-425
Baker, M.R., R. Bandaranayake and M.S Schweiger. 1984. Differences in the rate of immunisation among ethnic groups. BMJ 288:1077-9
Department of Health 2004. Immunisation Statistics. England: 2003-04. [online]. Available from
Date accessed 12 September 2005
Department of Health. 2005. Vaccination Services reducing inequalities in uptake. London.
Fitzpatrick, M. 2004. MMR and Autism. What parents need to know. Oxon: Routledge.
Healthcare Commission. 2004. 2004 Trust ratings. [online]
Available from
Date accessed 11-09-2005
Date accessed 17-09-2005
Houston M. The MMR Vaccine Controversy. The Irish Times 2002 Mar 4; Page 7, 15. Irish Times.
Ingram, M. 1995. Managing Immunization in General Practice. Oxon: Radcliff Medical Press Ltd.
Middleton, E, and D. Baker. 2003. Comparison of social distribution of immunisation with measles, mumps, and rubella vaccine, England, 1991-2001. BMJ 326: 854
NHS 2004. MMR The Facts. NHS Immunisation Information. [online]
Available from
Http://www.mmrthe facts.nhs.uk
Date accessed 11 September 2005.
Office for National Statistics. 2001. 2001 Census data. [online] Available from
Date accessed 11 September 2005
Twelvetrees, A.2002. Community Work. 3rd ed. Hampshire: Palgrave.
West Sussex Health Authority (2002). An Atlas of Deprivation Indices in West Sussex.
World Health organisation 2005a. [online]
Date accessed 10 September 2005.
World Health Organisation 2005b. Strengthening national immunization systems through measles and rubella elimination and prevention of congenital rubella infection in WHO’s European Region. Bucharest, Romania.
