Wirral Council: MMR insight case study

Wirral’s Health Protection Strategy 2023 to 2027 has seven priority areas, one of these is reducing vaccine preventable diseases. Of significant concern is the downtrend in Wirral’s measles, mumps and rubella (MMR) vaccination coverage, which reflects national trends. As well as decreasing uptake, there are considerable inequalities within Wirral. Not being able to attain herd immunity levels (greater than or equal to 95 per cent) increases the potential for the resurgence of measles, which is highly contagious and can cause serious complications including blindness, pneumonia, meningitis, seizures and in some cases, death.

Several key actions to improve uptake and inequalities in uptake were identified within the strategy. The aim of this project was to explore key motivators to MMR vaccination. Insights gathered were then evaluated to help to determine how local interventions and communications could be developed and enhanced.

Research aims:

• to understand any barriers to vaccination
• use this insight to develop solutions to help improve vaccination uptake rates
• pilot the Qualitative Insight Toolkit that Wirral Public Health’s Qualitative Insight Team (QIT) developed.

Target groups identified to take part in this research were:

• parents/carers of children who had both taken up and not taken up the offer of MMR vaccination(s)
• specific demographic/GP areas with low MMR vaccine uptake
• under-represented groups.

The Wirral Public Health team were mobilised to undertake this research as part of a month-long community insight gathering campaign. The specific objectives for the team were:

• to visit a range of early years activities and settings within Wirral to speak with parents and carers of young children (ideally those who have not yet started school), using a research grid template (resource within the Qualitative Insight Toolkit)
• undertake a minimum of 30-50 conversations over a month-long period starting July 2024
• record information from conversations using an inputting and analysis table
• undertake an analysis of insights gathered and produce a report setting out the results of the evaluation.

This study was primarily undertaken through capturing insight by way of informal semi-structured conversations with members of the public. A research grid was developed by QIT featuring a set of open-ended questions relating to the participant’s experience of the MMR vaccine and their views on different aspects of the uptake process. This method of collecting insight allowed researchers to focus the discussion on specific areas of interest, whilst still allowing the participant space to provide their own detailed response.

Basic participant demographics (age, gender, employment status and ethnicity) were captured to provide details of the characteristics of participants who took part in the study, as well as home address postcodes. Names of participants were not captured at any stage of this qualitative study to preserve anonymity.

A list of local settings was compiled where they would be able to connect with people who fit the criteria of target participants (parents, carers and/or anyone with responsibility for children).

Participants were then approached informally, with the research grid compiled for each person using written notes and no recording devices. Following an initial phase of insight capture with 73 participants, diversification of the initial sample focused on gaps in ethnic demography and socioeconomically deprived groups in a short term second phase.

The COM-B framework approach was adopted in analysing the responses, to help guide solutions for improvement. In addition, this also helped to provide a golden thread from research question to co-designing actions / intervention.

A brief summary of the findings has been broken down by motivators and challenges/barriers – identifying the three most common responses.

Motivators for vaccination

As part of the project, participants were asked what are or were their reasons for having their child or dependant vaccinated, with the 3 most common responses noted below.

• to protect their child/keep them healthy (n=53)
• advice from Health Professional, NHS or Family (n=11)
• to protect others/prevent illness (n=10).

To keep my children well and healthy. I don't want to end up in hospital with them if I can avoid it. It’s the best protection for them so why not?

Challenges and barriers to vaccination

To understand barriers, challenges or reasons for non-vaccination or a delay in vaccinating, participants were asked what was or is stopping them from having their child or dependent vaccinated, with the three most common responses noted below.

• availability and/or accessibility (n=26)
• lack of information/knowledge on the vaccine (n=6)
• purported links to autism and other health impacts (n=5).

Not really understanding what the vaccine is for and the health benefits it provides especially with being a first time parent.

Theme 1: Appointment availability

• Despite 24 per cent of children and dependents of participants being unvaccinated, the insights gathered from many of these parents does not indicate that this would be a permanent status for the child or that they were fundamentally anti-vaccination, more so that there were numerous accessibility factors affecting their decision. 
• An overwhelming theme of the insight gathered during this project was that a wider breadth of appointments is needed to allow improved access to the vaccine for Wirral residents, particularly families. Improved community outreach and more convenient appointment times would provide further choice and expected improved uptake.

Theme 2: Lack of knowledge 

• Barriers around finding and understanding key information relating to the MMR vaccine was a common theme between both those whose children are vaccinated and unvaccinated, this is despite findings showing that messages around getting the MMR vaccination are being disseminated.
• The public have shown that they wish to be armed with information around why the vaccination is important, as well as personal and community benefits, in addition to simply being asked to book their children in for an appointment. Some participants also acknowledged that they had queries around the vaccine that are already readily available online, such as side effects or vaccine ingredients.

The findings in this report identify several opportunities for the improvement in MMR vaccine uptake in Wirral:

• better promotion of comprehensive resources showing benefits of vaccine – potentially included in letter inviting parents
• explore the feasibility of widening the breadth of appointments for MMR vaccines across the borough, particularly to accommodate those with other children or larger families
• utilise community groups and other non-healthcare partners to ensure better dissemination of key information on the MMR vaccine to those in Wirral
• Make Every Contact Count (MECC).

Other councils could consider, the areas we have highlighted as ones which we could do differently if we were to repeat this insight again. These would strengthen a broader system level understanding to barriers and motivators for vaccination and jointly developed approaches to address.

Things you may have done differently in retrospect: 

• complemented resident insight with local insight with primary care, early years partners to create a fuller picture of perceived barriers and motivators local across Wirral
• held focus groups to gain an understanding of how to better equip / support health professionals and early years partners to pass on key information that respondents had highlighted, to parents and carers.

How effective has the project been? 

• achieved good engagement, with 73 participants contributing across a range of settings and demographics
• positively contributed towards existing national insight to understand the motivators and barriers to vaccination
• strengthened relationships with early years settings and community partners, supporting future engagement and delivery
• influenced local planning and communications activity, including integration into Best Start for Life and early years workstreams 
• identified clear, actionable themes (for example, access, information gaps), enabling more targeted intervention design
• demonstrated that many unvaccinated children are not from vaccine-hesitant families, but are affected by practical barriers, helping to reframe local assumptions 
• created opportunities to embed MECC approaches in frontline engagement 
• contributed to a more coordinated, system-wide response to improving vaccination uptake.

Wirral Council lead contacts

• Rebecca Mellor, Public Health Principal
• Lara Ashton, Senior Public Health Practitioner

Wirral Public Health Team members involved in the research:

• Helen Stott, Public Health Principal
• Alexandra Davidson, Public Health Practitioner
• Daryl Williams, Public Health Officer
• Clare Wright, Public Health Officer