Work summary

1. Work summary Discourse analysis - complete Development of invite letter templates – drafted and feedback gained Research with parents - complete Research with HCPs – Late August Trial and evaluation of interventions - Autumn Sign off and roll out – Spring 11

2. Mapping the linguistic landscape • Technical analysis of language used around MMR • Looking for patterns and anomalies – largely qual with some quant methods

3. MMR = a discourse of fear in media Emotionally charged metaphors esp. fire, natural disaster and warfare “Unlike most scientific controversies which flare up and die away, however, this one has simmered for a decade - and may now be fired up again by the preliminary verdicts in the GMC case.” (Independent) “Wakefield ... published his research ... which unleashed a tsunami of fear about MMR.” (Times) “His research paper ... sent shockwaves across the world of medicine and into the homes of families” (BBC News) “I was there when Wakefield dropped his bombshell” (Independent) “The Lancet knew it had a potentially explosive paper on its hands.” (Independent) “...battle over the safety of the MMR vaccine” (Times) This tendency more pronounced than in average media coverage: reflects the location of MMR across ideological tensions and fault lines

4. ‘The (misguided) middle classes’ vs. ‘the common good’ MMR poses a cultural paradox: educated people are rejecting a) science and b) the common good Provokes anxiety and some vicious attacks e.g. Mail Reflected in women's own language – ‘I’m not an evil mother’ ‘…middle-class twits like Joanne pottering around the kitchen brewing up potions‘ (Mail) One correspondent - a highly educated and intelligent woman - asserted that girls have died in the US from the vaccination, and implying that profit-seeking drug companies (with the connivance of governments, presumably) were prepared to kill our kids in order to make money. (Times) [The parents] are middle class and university educated, but they are behaving like morons. (Mail)

5. Ideological tensions: the ‘big’ cultural context • Science and rationality; logic, reason, evidence, ‘facts’ • Establishment authority: top down, ‘monologic’ voice • ‘The public good’ – an intellectual construction • Irrationality; myths, stories, ‘scares’, faith, belief • Emerging authority; peer-to-peer authority; ‘dialogue’ • Individual, basic, emotional, human needs Vs.

6. Headline comparison: main differences* between higher and lower SEG media cont. Lower SEG media uses simpler language. The language is less varied than higher SEG data, and there is less use of Latinate terms e.g. ‘immunisation’ (as we might expect). It is more colloquial – ‘kids’ and ‘mum’ and more conversational e.g. ‘Well, [Wakefield] didn’t stand a chance did he?’ (Mirror) Lower SEG features many more human-interest stories: e.g. we see more use of ‘I’ and personal names compared to higher SEG. There is more reference to kinds of family members in lower SEG than higher SEG, also suggesting human interest stories. Parents’ testimonials are an important way that arguments are made or presented in lower SEG (vs. e.g. use of numbers, authority figures or scientific arguments in higher SEG); also doctors are more often personalised. There is less focus on the collective good - ‘protect’ and ‘protected’ always occur with ‘children’/‘kids’ in lower SEG; while in higher SEG media this also occurs with ‘population’ or ‘individuals’. In addition, lower SEG data does not include abstract agents like ‘nation’, ‘state’ and ‘society’.

7. The absence of real dialogue – focus group transcripts “...if you go to the clinic they’ll just say, why hasn’t he had his vaccinations, and they’ll start scaring you, saying there is measles around. They kind of take that approach with you. They don’t say ‘have you got any concerns about it, or why...’ . I don’t find that that helpful, really.” (Depth 1) “[the doctor] turned round and she said ‘Oh some people have been like, you know, looking at what these celebrities do and think that they can come into here and …’ and that was a little rant. And I was like ‘oh my God how can you say this to me?’ I am a mother, you see my child, you see that I am concerned. I am not crazy, I am speaking to you nicely” (Depth 4) “Just basically them trying to convince us to allow my little girl to have it but obviously I’ve raised the same issues that I’ve raised here and, you know, they can’t give you that information [re: the risks of MMR] because half the time they don’t know it themselves. You know, to me, they’re like robots basically” (Depth 7) “You don’t actually need to go into all of this. That could have been small and even more punchy. You know, ‘Don’t leave your child’s health to chance. Just get the immunisation!’” (Immunisation Officer)

8. Parents’ (i.e. mums’) websites Amplified version of the tensions seen in other areas Highly emotional esp. mumsnet.com; MMR a highly contested subject Gendered – one poster ‘accused’ of being male through tone of his/her argument Mums’ own research can be deep and highly specific – they post academic articles for others to read Scathing about NHS ‘party line’ - and brutally to the point: “Measles being dangerous does not make MMR safe” Longing for real information, but within a dialogue – have to look to the peer group for this, but room for DH to take a different approach I can see why they might not want a measles epidemic, but if tactics so far haven't worked to increase numbers then perhaps they should try another. They have been shouting the MMR is safe line for years, Wakefield's reputation is now destroyed. If people still refuse MMR then maybe they need to look at why and approach the public differently (mumsnet.com post 24th Feb 2010)

9. Engage in dialogue – properly Conversations, not ‘messages’ Extrapolate from mediation, conflict management and negotiation; need first to show adversaries that they are heard and respected by each other Construct a different relationship between health care providers (and the institutions behind them) and parents, esp. mothers not parent/child – ‘we know best’ – clearly not working nor a gendered asymmetry of power – clearly retrogressive BUT an adult-adult, respectful and/or use a more human approach, replacing institutional authority with peer authority (this suggestion comes from looking at the lower SEG media data) NB implications for ‘behaviour change’ BUT in HCPs and ‘authority voices’ – not just in parents. Implications for interventions: thoughts from the discourse perspective

10. PCT letters: seem unlikely to connect with parents Obligation prominent; pressurising without recognising where parents start from Cumbersome and stilted; poor grammar, spelling and punctuation could make the sender seem untrustworthy to educated parents In addition: some problems common in public sector comms: Sense of self-absorption and lack of focus on the reader Concerned with own official discourse, not what will make most sense to readers Clash between the private world of the parent and the public sphere of health institutions

11. Parents focus groups – top line interim findings Four groups held in Newham and Kensington & Chelsea early august 2010 Barriers to uptake Feeling that HCPs don’t have time to discuss concerns and in some cases not willing / able to Overall experience of immunisations generally can be negative, some uncomfortable ‘holding down’ children whilst injection given and would rather other HCP does this (but others want to do themselves) Environment where immunisations given not very child friendly / pleasant adding to negative experience Some cynicism of NHS who are seen to be driven by targets and payments MMR in particular seen as a ‘cocktail’ of drugs and concerns about being unnatural. Link with autism prevalent but not all encompassing Immunisation schedule is perceived as complex and long and don’t feel have enough information on it

12. Parents focus groups – top line interim findings Potential interventions HCP training to ensure willing / able to address parents concerns and ability to spend time with concerned parents Possibility of other HCP holding child whilst injection given Environment where immunisations given softer with toys etc. Work with respected children's charities to communicate benefits of immunisations Review information provided to new parents to assess usefulness. Is different format useful. But, are parents receptive. Timing