Exploring vaccination attitudes in a high-uptake county: a coordinated system approach to tackling hidden inequalities

Wiltshire maintains generally high vaccination uptake however, declining coverage in key vaccinations such as MMR and the pre school booster, alongside local variation, increased the risk of vaccine-preventable disease outbreaks and prompted action to better understand and respond.

Wiltshire is a large, predominantly rural county with diverse communities, including a significant military presence, nomadic populations including Gypsy, Roma, Traveller and Boaters (GRTB) and growing migrant communities. This creates a complex landscape for vaccination delivery and uptake.

Through the Wiltshire Immunisation Group (WIG), the county’s multi-agency partnership overseeing immunisation activity, it became clear that high overall coverage masked local variation, highlighting the need to better understand barriers to access and attitudes across communities.

While national insight provided context, it was insufficient to address local challenges. This prompted a focus on generating Wiltshire-specific insight and strengthening the WIG’s role in coordinating a structured, community-informed response, with targeted research commissioned to inform interventions and improve collaboration.

The project aimed to develop an evidence based understanding of vaccination attitudes, barriers and inequalities in Wiltshire to inform targeted action for local communities.

Key objectives were to:

• understand local drivers of vaccine uptake including attitudes, access challenges and inequalities
• identify priority communities and areas for targeted intervention, alongside effective engagement approaches
• use the evidence to develop a coordinated immunisation action plan to support local delivery
• strengthen the role of WIG to support more collaborative, strategic, action focused working.

Healthwatch Wiltshire was commissioned to deliver the research, recognising its role as an independent organisation with established community relationships, enabling more trusted engagement. 

A mixed-methods approach was used:

• a county-wide survey (456 responses) targeting parents, carers and pregnant people, framed around the ‘3 Cs’ model of vaccine hesitancy
• in-depth qualitative engagement (34 sessions including focus groups and interviews), prioritising priority groups including military, migrant and traveller communities.

To translate insight into action:

• a report was produced summarising findings, supporting shared understanding across partners and informing next steps
• an immunisation summit brought together partners across the system including core immunisation partners (Local Authority Public Health, NHS England, Integrated Care Board, vaccination outreach, School aged Immunisation, Child Health Information Services) and wider partners such as education, children’s services, communications, military, resettlement and community teams. The aims were to share findings, build a shared understanding and take a whole systems approach to coordinated action.
• a WIG data workshop involving core immunisation partners reviewed local vaccination data (pre natal, 0 to five years and school aged) to identify areas of lowest uptake and agree priority vaccines for the action plan.

Together, these activities informed the development of a targeted immunisation action plan and improved coordination across partners.

The Healthwatch research provided an evidence base for action, enabling WIG to adopt a more targeted, local intelligence-led approach.

A key output has been the development of a system immunisation action plan, structured around four themes:

• building trust and community relationships
• workforce training and capacity building
• tailored communications
• improving accessibility.

This provides a shared framework for coordinated action across partners and helps align existing activity.

The programme has begun to strengthen the role of the WIG, supporting its development towards a more strategic, action-focused approach. There has been early progress in improving collaboration, with work underway to strengthen cross-sector engagement and information sharing.

Embedding community voice into planning has supported more culturally appropriate and accessible interventions, increasing the likelihood of improving uptake among underserved groups.

Overall, the programme has established a foundation for place-based, equity-focused working and ongoing system learning.

The project showed that high overall uptake can mask local inequalities, reinforcing the need to focus on variation at a community level. It also highlighted that high coverage does not equate to an absence of hesitancy.

Vaccine hesitancy in Wiltshire reflects the recognised ‘3 Cs’ model. While some concerns were linked to confidence and perceptions of disease risk, the most reported barriers were related to convenience, including access to services, appointment availability and service design. This reinforces the need to focus not only on communication, but also on improving accessibility.

A key learning was the value of combining data with person-centred insight to contextualise variation and ‘bring the data to life’, strengthening understanding and engagement across partners. Qualitative insight provided depth and ensured the voices of priority groups often underrepresented in survey data, were included.

The programme reinforced that tackling inequalities is a whole-system responsibility, with a wider range of partners influencing access and attitudes. It also highlighted the opportunity to strengthen the role of WIG through a more strategic, action led approach to better align activity and support coordinated delivery. For example, communication materials were not always shared across partners, limiting consistent messaging and creating a risk of duplication.

The project has been effective in strengthening the local evidence base and aligning partners around shared priorities. While not based on a novel model, a more structured and strategic use of existing arrangements has improved coordination and focus.

Feedback highlighted the value of the immunisation summit in bringing partners together face-to-face to share learning, strengthen relationships and identify opportunities for joint working. As one participant noted, it provided an “opportunity to network with colleagues… often targeting similar groups,” reinforcing the need to better align activity across the system.

While longer-term impacts on uptake are still emerging, the programme has established a clear framework for action. The immunisation action plan and evolving role of WIG provide a sustainable platform for continued progress, now embedded into ongoing work.

This has supported more sustained relationships with communities through routine delivery, reducing reliance on one-off engagement. Links have also been strengthened with the Council’s Community Conversations  team to support ongoing dialogue with residents.
Themes from the immunisation work including trust, accessibility, workforce capacity and community engagement, align with themes identified in wider public health priorities, highlighting opportunities to connect across programmes and support a more coordinated, system-wide approach.