Impact of an influenza information pamphlet on vaccination uptake among Polish pupils in Edinburgh, Scotland and the role of social media in parental decision making.

BACKGROUND: In Edinburgh, Scotland, lower influenza vaccine uptake has been observed in primary school children in the Polish community. METHODS: To address this disparity, the Polish-language version of the NHS Health Scotland influenza information pamphlet was updated and distributed in 2018 to all identified Polish pupils attending three pilot schools. The impact of the revised pamphlet was evaluated by examining changes in vaccine uptake in these schools as compared to a control group of schools, and a questionnaire was issued to all Polish parents in the pilot schools to explore their opinions of the pamphlet and preferred sources of immunisation information. RESULTS: On average uptake was 7.4% (95% CI 1.0-13.8%, p < 0.05) higher in the three pilot schools in which the Polish-language pamphlet was distributed (28.7%) than control schools (21.3%). The questionnaire feedback was that 37.3% of respondents felt better-informed about the influenza vaccine following the pamphlet. The respondents reported that the most important information source in deciding whether to vaccinate is previous experience. Healthcare professionals were ranked lower in importance when making a decision. Parents, who refused consent (n = 65) were more likely to source information from social media, friends and family, and Polish websites compared with those who consented (n = 45). CONCLUSIONS: These findings suggest that issuing new Polish health literature was associated with a large increase in consent form return rate and a modest increase in uptake of the influenza vaccine by Polish pupils in the pilot schools. Social media and Polish websites were found to have a greater influence over Polish parents' decision to immunise than UK healthcare staff and health authority information. Intensive effort is required to encourage parents towards information sources where more accurate pro-vaccination messages can be promulgated by national health services and independent expert groups. The role of social media for migrant communities requires careful consideration, especially for vaccine programmes not delivered in their country of birth.

Comparing vaccination hesitancy in Polish migrant parents who accept or refuse nasal flu vaccination for their children.

This study investigates the background to low uptake of nasal influenza vaccination in Polish pupils in Edinburgh, Scotland. In autumn 2018, one week after their child's nasal flu vaccination sessions, 365 Polish parents were sent a questionnaire exploring influences on their vaccination choices. The questionnaire included a series of 10 vaccine hesitancy questions recommended by the WHO SAGE Working Group on Vaccine Hesitancy. 128 questionnaires were returned representing 43.4% of vaccinated, 41.9% of refusing and 23.8% of non-consent form returning parents. Responses highlighted concerns about side effects, new vaccines and the accuracy of professional advice and information sources. There was complacency expressed about vaccination against diseases that are not common any more. Vaccine refusers were consistently more negative about all aspects vaccination and more likely to answer 'don't know'. Almost half of refusers were uncertain about the quality of health information offered to them. Polish migrants in Scotland come with their beliefs about vaccination and modify these as they acculturate to the UK system. They also continue to be influenced by developments and opinions, norms and values from their home country, as well as diaspora media. We have highlighted issues of concern among Polish migrants as a group and gained additional insights by comparing responses of parents who have refused or accepted vaccination. These insights can inform and target messages and strategies to build confidence and encourage immunisation, which should lead to improved vaccine uptake among ethnic population groups.

A qualitative study of vaccination behaviour amongst female Polish migrants in Edinburgh, Scotland.

Vaccine hesitancy is increasing and failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. In Lothian and Scotland, low vaccine uptake has been seen in migrants - notably in the Polish group who have arrived since 2004. The recent Vaccine Confidence in European Union report highlights a concerning recent decline in vaccine confidence in Poland. We held three focus groups containing 13 Polish women about the childhood vaccination programme in Lothian, with specific focus on influenza and Human Papillomavirus vaccinations. Key emergent themes were: trust in the national vaccination policy, trust in the vaccination providers (health professionals), trust in the individual vaccines, balancing the risk of disease, and language and communication. Polish norms, beliefs and behaviours shape how Polish migrants navigate the UK health system and its vaccination programme. While not confident in the Scottish primary care model and its generalist practitioners, the participants liked the ethos of informed consent in Scotland and compared this favourably with the compulsory vaccination policy in Poland. There was a belief that vaccines in Scotland were of higher quality than Poland and with fewer adverse effects. Respondents reported returning to Poland for specialist clinical appointments and diagnostic testing. They regularly access Polish clinical expertise and their opinions about health are influenced by Polish friends and family. They say they have difficulty finding official UK Government and health authority vaccination material and often access Polish media, online resources and information. They are familiar with anti-vaccination activities in Poland. Consequently, there are important unmet information needs for this group of parents who may not be making truly informed choices about vaccination. This requires further investigation especially as migration continues and declining immunisation uptake is reported in many countries across Europe.

Evidence of decreased HPV vaccine acceptance in Polish communities within Scotland.

Human papillomavirus (HPV) vaccines are currently utilised globally in national immunisation programmes. Many new European migrants have settled in the United Kingdom (UK) since the 2004 European Union expansion with approximately 91,000 Polish people resident in Scotland. Following anecdotal reports from several NHS Boards within Scotland of lower HPV vaccine uptake in Polish communities compared with other ethnic minorities, an extract containing both forename and surname, was taken from the Scottish Immunisation Recall System (SIRS) for all girls in S2 and S3 in school years 2014/15 to 2016/17. We then used the OnoMap algorithm software to derive ethnicity. OnoMap identified between 289 and 321 age-eligible girls as Polish with significant disparity noted for completed HPV vaccine uptake between UK (87.2-89.8%) and Polish ethnicities (69.7-77.2%) (P < 0.01). Preliminary discussions with Polish families suggest that vaccine programme differences, trust in medical/healthcare practitioners, and cultural influences may be important drivers of acceptance.

Low uptake of nasal influenza vaccine in Polish and other ethnic minority children in Edinburgh, Scotland.

Failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. Low immunisation rates are often associated with religious, social and ethnic minorities, including refugees or migrant groups. Polish people form Scotland's newest and largest migrant group. They have moved to Scotland since 2004, joining established ethnic minorities from China, the Indian subcontinent and Africa. Scotland has had a seasonal influenza nasal vaccination programme for all primary school children since 2013. We investigated three primary schools in Edinburgh, which had reported low influenza vaccination uptake rates in 2016 and 2017 and found that these schools contained many pupils from ethnic minorities, the majority of whom were Polish. Pupils were categorized as one of three ethnic groupings: White British, Polish and Other Identified Ethnic Minority (OIEM). We ascertained ethnicity using NHS and Education Department information sources and name recognition. We examined vaccine acceptance, declination and non-return of consent forms. In 2017, nasal influenza vaccine uptake was 70.7% (65.2-75.6%, p < 0.001) in White British, 60.9% (53.9-67.6%%, p < 0.001) in other identified ethnic minorities and 25.0% (20.9-29.6%, p > 0.001) in Polish children. White British children were more likely to return completed forms (78.9%) than other groups (OIEM 68.2% and Polish 61.8%). 36.8% of Polish families completed a consent form declining vaccination compared to 6.2% of White British families. These findings demonstrate that significant differences exist in nasal influenza vaccination uptake rates, which have important implications for the trans-national study of vaccine hesitancy. Further qualitative work and an investigation of uptake rates of other childhood immunisations in Polish and other migrant groups is required to assess differences in uptake and behaviours.

Using electronic maternity records to estimate female genital mutilation in Lothian from 2010 to 2013.

Background: Female genital mutilation (FGM) is most commonly encountered in Africa and the Middle East, with migration from FGM-practicing countries meaning it is increasingly seen in Europe. Addressing FGM requires accurate information on who is affected but ascertainment is notoriously difficult. This study estimated FGM prevalence in women presenting for maternity care in the Lothian region of Scotland and compared this with that expected by extrapolation of survey data from women's country of birth. Methods: Electronic clinical records were linked to birth registration data to estimate FGM in the obstetric patients in Lothian from 2010 to 2013. Results: Among all, 107 women affected by FGM were detected, at a rate of 2.8/1000 pregnancies. Of 487 women from UNICEF-recognized FGM-practicing countries who accessed care, 87 (18%) had documented evidence of FGM (three quarters of whom came from Nigeria, Sudan or The Gambia). The prevalence was 54% of the level expected from the extrapolation method. Country of birth had a sensitivity of 81% for FGM. Conclusion: Women from FGM-practicing countries commonly access maternity care in Lothian. This confirms the need for ongoing training and investment in identifying and managing FGM. Matching electronic clinical records with birth registration data was a useful methodology in estimating the level of FGM in the maternity population. In a European country like Scotland with modest migrant numbers, asking country of birth during pregnancy and making sensitive enquiries could detect 81% of women with FGM. Extrapolation from maternal country of birth surveys grossly overestimates the true prevalence.

Influences on Polish migrants' breast screening uptake in Lothian, Scotland.

OBJECTIVES: Ethnic minorities are known to have low uptake of cancer screening programmes and Polish populations to have low breast screening uptake. Breast screening uptake by women in Poland and Polish migrants to Scotland is low. We interviewed Polish women living in Lothian, Scotland, about their attitudes to breast screening. STUDY DESIGN AND METHOD: Telephone interviews were held with a sample of 11 Polish women registered with Lothian general practices and invited for breast screening in 2013 or 2014. Interviews were between November 2014 and February 2015 and were held in Polish then translated, transcribed and analysed thematically. RESULTS: Women interviewed (mean age 58 years) had lived in Scotland for an average of 7.5 years. Seven had undergone breast screening in both Poland and Scotland, three in only Scotland and one in Poland alone. Respondents usually used Scottish and Polish health systems and screening programmes in parallel. Convenience and familiarity shaped screening choices with written information neither accessed nor answering key questions e.g. about coordination between programmes. CONCLUSION: Polish women living in Scotland have difficulties in accessing screening there and often use both Polish and Scottish system. Language issues, misunderstandings about screening and different health cultures are key barriers. Combined information in Polish about all cancer screening programmes could help address low uptake.

Ethnic variation in maternity care: a comparison of Polish and Scottish women delivering in Scotland 2004-2009.

OBJECTIVES: Birth outcomes in migrants vary, but the relative explanatory influence of obstetric practice in origin and destination countries has been under-investigated. To explore this, birth outcomes of Scots and Polish migrants to Scotland were compared with Polish obstetric data. Poles are the largest group of migrants to Scotland, and Poland has significantly more medicalized maternity care than Scotland. STUDY DESIGN: A population-based epidemiological study of linked maternal country of birth, maternity and birth outcomes. METHODS: Scottish maternity and neonatal records linked to birth registrations were analysed for differences in modes of delivery and pregnancy outcomes between Polish migrants and Scots, and compared with Polish Health Fund and survey data. RESULTS: 119,698 Scottish and 3105 Polish births to primiparous women in Scotland 2004-9 were analysed. Poles were less likely than Scots to have a Caesarean section and more likely to have a spontaneous vaginal or instrumental delivery. The Caesarean section rate in Poland is significantly higher and instrumental delivery rate lower than for either group of women in Scotland. CONCLUSIONS: Methodologically, comparing a large group of migrants from one country with the host population has advantages over grouping migrants from several countries into a single category, and allows more informed analysis of the effect of health services. Polish mothers' being slightly healthier explains some of their lower Caesarean section rate compared to Scots in Scotland. However, dominant models of obstetrics in the two countries seem likely to influence the differences between Poles delivering in Poland and Scotland. Further investigation of both is required.

Name analysis to classify populations by ethnicity in public health: validation of Onomap in Scotland.

OBJECTIVES: Health inequalities between ethnic minorities and the general population are persistent. Addressing them is hampered by the inability to classify individuals' ethnicity accurately. This is addressed by a new name-based ethnicity classification methodology called 'Onomap'. This paper evaluates the diagnostic accuracy of Onomap in identifying population groups by ethnicity, and discusses applications to public health practice. STUDY DESIGN: Onomap was applied to three independent reference datasets (birth registration, pupil census and register of Polish health professionals) collected in Britain and Poland at individual level (n = 260,748). METHODS: Results were compared with the reference database ethnicity 'gold standard'. Outcome measures included sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Ninety-five percent confidence intervals and Chi-squared tests were used. RESULTS: Onomap identified the majority of those in the British participant group with high sensitivity and PPV (>95%), and low misclassification (<5%), although specificity and NPV were lowest in this group (56-87%). Outcome measures for all other non-British groupings were high for specificity and NPV (>98%), but variable for sensitivity and PPV (17-89%). Differences in misclassification by gender were statistically significant. Using maiden name rather than married name in women improved classification outcomes for those born in the British Isles (0.53%, 95% confidence interval 0.26-0.8%; P < 0.001) but not for South Asian or Polish groups. CONCLUSIONS: Onomap offers an effective methodology for identifying population groups in both health-related and educational datasets, categorizing populations into a variety of ethnic groups. This evaluation suggests that it can successfully assist health researchers, planners and policy makers in identifying and addressing health inequalities.

Obstetric care of new European migrants in Scotland: an audit of antenatal care, obstetric outcomes and communication.

BACKGROUND AND AIMS: There has been a twelve-fold increase in the number of New European migrants giving birth in Lothian between 2004 and 2007. The objective of this study was to audit obstetric care standards in Lothian for new migrants and recommend service improvements. METHODS: A retrospective audit of 114/136 (84%) obstetric case records of new European migrants giving birth in Lothian hospitals in 2006 was conducted. Assessment was against care standards for antenatal booking, antenatal attendance and interpretation. Obstetric outcomes were audited against the general population. RESULTS: Eighty percent were primiparous. Fifty five percent had booked by the end of week 14. Mean birth weights and lengths of stay were similar to the general population. Intervention rates were 23% for Caesarean Sections (C/S) and 17% for instrumental deliveries (versus 27% and 19% respectively in the general population). Epidural or spinal anaesthesia was used for 57% compared to 50% of the general population. The interpretation services (ITS) were used infrequently. CONCLUSIONS: Full compliance with antenatal and interpretation standards was not achieved for this population. ITS was most commonly used to meet the needs of healthcare professionals, rather than as a routine. While there were no significant differences in maternity outcomes, poor communication did affect care.

How has legislation restricting paracetamol pack size affected patterns of deprivation related inequalities in self-harm in Scotland?

OBJECTIVE: To describe how changes in legislation to control sales and thus restrict the general availability of paracetamol have affected deprivation-related inequalities in deliberate self-harm associated with the drug in Scotland. DESIGN AND SETTING: A descriptive analysis of routine death and hospital discharge data for the entire Scottish population between 1995 and 2002. PARTICIPANTS: Patients in Scotland admitted to hospital with a diagnosis of poisoning and deaths in Scotland due to poisoning 1995-2002. OUTCOME MEASURES: Changes in mortality and overdose rates by deprivation quintile, and case fatality rates due to poisoning involving paracetamol. RESULTS: Rates of overdose involving paracetamol, while much higher in disadvantaged quintiles, fell in each deprivation quintile following the 1998 legislation. They then returned to levels similar, or above those in the mid 1990s. All quintiles were affected to a similar extent with the relationship between them remaining constant over time. Case fatality rates were significantly higher in more disadvantaged quintiles. CONCLUSIONS: Marked inequalities exist in paracetamol related harm in Scotland. The most disadvantaged groups (both male and female) have higher overdose and death rates, as well as higher case fatality rates. Following the restrictions all social groups saw similar reductions in paracetamol related harm. This effect has been short-lived and rates have returned to pre-legislation levels. Legislation has not permanently affected overall use of paracetamol in overdose in Scotland or reduced the proportion of patients taking paracetamol as a component of the overdose in the longer term. An important public health policy has failed to achieve its objective and it is not clear why. We need a better understanding of why this measure had only short-term benefits if its full potential is to be achieved.

Legislation restricting paracetamol sales and patterns of self-harm and death from paracetamol-containing preparations in Scotland.

AIMS: To describe how changes in legislation to restrict paracetamol sales have affected overdose discharges and death associated with the drug in Scotland. METHODS: A descriptive analysis of routine death and hospital discharge data for the entire Scottish population between 1995 and 2004. Patients in Scotland participated who were discharged from hospital with a diagnosis of poisoning; deaths in Scotland from diagnosis of poisoning 1995-2003 were also analysed. Outcome measures were changes in mortality and overdose due to poisoning involving paracetamol. A comparison was made of in-hospital and out-of-hospital mortality in fatalities involving paracetamol. RESULTS: The majority of paracetamol-associated deaths were due to co-proxamol. Deaths associated with paracetamol alone or with ethanol occurred principally in hospital and were a minority of deaths overall. The proportion of in-hospital deaths attributed to paracetamol increased (post/pre ratio 1.347; 95% confidence interval 1.076, 1.639; P = 0.013). Overall numbers of cases discharged with poisoning fell. The proportion of these involving paracetamol in any form increased significantly in all groups except young men aged 10 to <20 years. CONCLUSIONS: Legislation has not reduced mortality or proportional use of paracetamol in overdose, both of which appear to have increased in Scotland since pack-size limitations. Other approaches are necessary to reduce the death rate from overdoses involving paracetamol.

Unintentional home injury in preschool-aged children: looking for the key--an exploration of the inter-relationship and relative importance of potential risk factors.

OBJECTIVE: To investigate the physical, social and psychological environment of families with preschool-age children to identify the most significant risk factors for unintentional injury. DESIGN: A 1-year prospective case-control study, using a health-visitor-administered questionnaire. SETTING: East and Midlothian, Scotland. SUBJECTS: Seventy-nine children under 5 years of age presenting to an accident and emergency (A&E) department during 1998-1999 with an unintentional home injury and 128 matched controls. RESULTS: Of 264 families, 207 responded (78.4% response rate). The main carers of cases had a lower level of educational attainment than controls (P<0.01). This factor explained the case carer leaving fulltime education earlier, being less likely to be married and more often in receipt of government benefits. Cases lived in households with larger numbers of children, were more likely to have a physical illness, were less likely to have had a non-medically attended injury in the previous year (P<0.01) but more likely to have had another A&E injury attendance. Case households had lower electrical socket cover utilization (P<0.01) and fewer thought their child had adequate access to safe play areas. The main carers of cases tended to have a more negative life event experience in the preceding 6 months, but showed no significant differences in physical or mental well-being or social support. Cases seemed to be slightly more deprived members of their community. CONCLUSIONS: The main carer's educational attainment and socket cover utilization were lower in case families. These risk factors could be used to target families for injury-prevention work. Initiatives to raise educational achievement in the general population could lead to reductions in childhood injuries.

The association between deprivation levels, attendance rate and triage category of children attending a children's accident and emergency department.

OBJECTIVE: To determine the relation between deprivation category, triage score and accident and emergency (A&E) attendance for children under the age of 13. DESIGN: Retrospective study of all children attending an A&E department over one year. SETTING: A paediatric teaching hospital in Edinburgh. SUBJECTS: All children attending the A&E department who had a postcode and a triage score documented on attendance. The postcode was used to determine the deprivation category and the triage scored the severity of illness or injury. MAIN OUTCOME MEASURE: The relation between deprivation category, triage score and frequency of attendance. RESULTS: There is a trend towards increased attendance in all triage categories for deprivation categories 6 and 7. CONCLUSIONS: Attendance at A&E is not only related to severity of injury but also to deprivation category. The reason why people from disadvantaged areas attend more frequently needs further evaluation.

The general practice perspective on cancer services in Lothian.

OBJECTIVES: The aim of the present study was to obtain views from general practices about current and potential improvements to services for patients with suspected lung, large bowel, non-melanoma skin and breast cancer. METHOD: A questionnaire study was carried out of 134 general practices within the Lothian Health Board boundary. Information was sought about referral choices, communication, quality of care, liaison between community and hospital, health promotion, treatment outcomes and palliative care. Main outcome measures were determinants of primary care referral behaviour and clinical investigation strategies, and perception of quality in secondary care and health promotion services. RESULTS: Seventy-nine general practices (59%) returned completed questionnaires. One-fifth of practices maintained a cancer register, and 85% provide patient information about cancer prevention. Initial management was disease dependent. Most cases of suspected lung cancer, about half of suspected colorectal cancer cases and very few cases of suspected breast cancer were investigated in primary care before referral to hospital. Hospital referral depended on knowledge of local services. A minority of practices wanted referral guidelines. It was estimated that 92% of lung and breast cancer cases, 68% of colorectal cancers and 35% of skin cancers are seen within 4 weeks. Breast cancer care was rated more highly than that for other cancers. One-third ranked community nursing support as 'excellent' and 10-15% described it as 'fair' or 'poor'; 77% describe palliative care as 'excellent' or 'good'. Fifty-one percent believe that communication with hospital is 'excellent' or 'good'. Practices were sometimes unaware of the hospital's post-diagnosis management plan; communication was often too slow and practices often received 'poor' advice about symptom control. Eighty percent thought that hospital follow-up for breast, colorectal and lung cancer should be routine; 20% thought that it was indicated for non-melanomatous skin cancer. CONCLUSIONS: Communication problems between primary and secondary sectors need to be tackled innovatively and the perceived quality variation in services addressed-perhaps by developing local guidelines. Practices would welcome further education about health promotion resources and cancer epidemiology.

Uptake of the children's traffic club in Lothian.

OBJECTIVE: To calculate the uptake of the Children's Traffic Club in Scotland (CTCS) in Lothian and the road traffic casualty rate of children aged 0-14 living in areas with different deprivation categories. DESIGN: Analysis of road traffic accident hospital admissions, 'STATS 19' (road traffic accident police reports) and CTCS uptake data in affluent, 'intermediate' and disadvantaged households. SETTING: The Lothian Health Board area. RESULTS: Affluent households have both the highest CTCS uptake rates and the lowest rates of road traffic accidents. The most disadvantaged populations have hospital discharge rates over three times that of people living in more affluent parts of Lothian. CONCLUSIONS: Minor changes in how the CTCS is run and fostering a multiagency approach to childhood accident prevention could improve both CTCS uptake and effectiveness of road safety measures.

Using routine accident and emergency department data to describe local injury epidemiology.

All 17330 Accident and Emergency Department (A and E) attendances following injury (67% of all A and E attendances by residents of the EH54 postcode (the town of Livingston) at St John's Hospital during 1995 and 1996 were examined to study local accident epidemiology. The overall annual injury attendance rate for males (245.7/1000) and females (148.0/1000) and sex and age group analyses show recognised patterns reflecting occupation and domestic circumstances. Higher attendance rates were associated with greater deprivation and living close to the hospital. The unique injury coding system used by the hospital offers the potential to highlight particular injury types occurring within population sub-groups. When linked with primary care and out-of-hours centre data, this could be useful in targeting preventive activities; this will be facilitated in this hospital, which will become part of a 'combined' acute and primary care trust from April 1999.

Under representation of morbidity from paediatric bicycle accidents by official statistics--a need for data collection in the accident and emergency department.

OBJECTIVES: To determine the accuracy of currently available data on bicycle related injuries in children. SETTING: A paediatric accident and emergency (A&E) department which annually treats approximately 30000 new patients under the age of 13 years. METHODS: Data on all attendances with bicycle related injuries over a four week period were compared with that currently available from police road traffic accident data (Stats 19) and the International Classification of Diseases, 10th revision, hospital discharge coding. RESULTS: Eighty six children attended the A&E department. Only two bicycle related injuries were identified from Stats 19, and 10 from hospital discharge data. CONCLUSION: Currently available official data do not give an accurate representation of the incidence of bicycle related injuries in children. If health promotion measures are to be assessed properly data collection needs to be improved.

A survey of infertility practices in primary care in Scotland.

An 83% response rate was obtained to a postal questionnaire survey of general practitioners (GPs) carried out as part of a national infertility audit in Scotland. This provided information about how GPs are managing infertility and their opinions on 12 suggested criteria for good practice in a primary care setting.