Moving the Needle: Promoting Vaccination Uptake across the Life Course

"It is clear that the reasons for complying or refusing to vaccinate are complex and influenced by external factors - health professionals, the media, peers, social norms - as well as internal values."

With the dawn of social media, information - and misinformation - about vaccines can spread further and faster than ever before, according to this report from the Royal Society for Public Health (RSPH). The report aims to contribute to the conversation by exploring vaccination in the United Kingdom (UK), investigating the role of and barriers to vaccination at different stages of the life course: through childhood, working-age adulthood, and later life.

The report begins with a history of vaccination, discussing its benefits at the individual and population levels. Despite these benefits, there has been opposition to vaccination since its discovery, for a number of reasons. Vaccines were originally met with scepticism of science and fear of the loss of civil liberties. Another reason for opposition has been concerns around side effects. An oft-cited case is the officially discredited 1998 study led by the UK's Andrew Wakefield, in which he incorrectly suggested a link between the measles, mumps, and rubella (MMR) vaccine and autism. The study caused widespread mistrust of the vaccine, reaching anti-vaccination groups across the world and fuelling modern anti-vaccination sentiment. Concretely, the result of the MMR scare - and the controversy that ensued - was a drop in uptake of the vaccine, with a low of 79.9% of children in England receiving their first dose of the MMR vaccine by their second birthday in 2003-04 (far below the 95% level that the World Health Organization (WHO) recommends for herd protection). Misconceptions still remain around the safety of the MMR vaccine, which highlights the impact of negative press around vaccinations and the vulnerability of vaccination programmes to fear and misunderstanding.

In recent times, anti-vaccination movements have particularly focused on the human papillomavirus (HPV) vaccine, claiming that the vaccine has led to severe side effects and deaths. For instance, a video published on YouTube in September 2017 has over 92,000 views and states that there have been "hundreds of documented deaths following the HPV vaccine" and "thousands around the world have suffered severe adverse reactions to the vaccine". There has also been media coverage around the issue, focusing on specific cases of possible reactions to the vaccine.

A further element of refusal to vaccinate may be that as incidence of disease declines, people feel less at risk from the disease, or fail to realise how serious the disease is, and so the incentive to vaccinate is reduced. However, the very high uptake of routine childhood vaccines in the UK, despite extremely low incidence of disease, indicates a more complex picture. It is suggested that social norms play a large part in this through the threat of social "sanctions" if parents fail to follow the norm.

To inform the lifecourse approach pursued in this paper, RSPH carried out a narrative literature review and 3 public surveys of nearly 5,000 peole (2,600 parents, 2,000 other adults, and more than 200 healthcare professionals) across the UK on their awareness and attitudes towards vaccines such as those protecting against MMR, influenza, and HPV.

In childhood and adolescence, accessibility and convenience of vaccination services can be important determinants of vaccine uptake - this may be particularly true for parents who are not explicitly anti-vaccination but may be hesitant. Roughly one in 10 parents surveyed said they had chosen not to give their child the MMR shot. The main reasons given were doubts over whether the vaccine worked, followed closely by concerns over side effects. For the flu vaccine, 1 in 5 parents chose not to give it to their child, while 1 in 14 refused an HPV vaccine for their teenage daughter. Again, those parents expressed worries over unwanted side effects. Low coverage of vaccines is particularly seen in smaller ethnic communities, and reasons for low uptake can be complex and specific to local populations. (RSPH observes that a limitation of the surveys is a low representation of minority ethnic groups.)

On the whole, the report found parents' attitudes to vaccines were largely positive, with 90% getting their children vaccinated routinely. Parents also demonstrated a high level of understanding of vaccinations, with 89% agreeing that vaccinations protect others around their children as well as their children themselves. Parents identified scientific experts and doctors and nurses as the most trusted sources of advice, with 94% and 92% respectively saying they were valued sources of information.

Of concern, however, is the finding that as many as 2 in 5 parents with children under the age of 18 said they are exposed to negative messages about vaccinations online "often or sometimes": 41% on social media and 38% on online forums. This rose to 1 in 2 among parents with children under 5 years old (50% and 47%, respectively). Although only 10% parents claimed they would trust people on social media or on online forums, this substantial exposure to negative vaccination messages may influence attitudes to vaccinations over time: Repetition of messages is often mistaken for accuracy. The opinions of people online regarding vaccinations were trusted by around 1 in 5 millennials, with 17% of 18-24 year olds and 21% of 25-34 year olds agreeing they trusted the opinion of people online through social media or forums. This was much higher than in older age groups (4% in those 55 and over). People in all age groups said they were more likely to see negative messages about vaccines on social media than positive ones. Parents can also be heavily influenced by negative headlines in newspapers and online, and, as discussed above in relation to the Wakefield scandal, it can take a long time to change people's perceptions.

Unlike childhood vaccines, the decision to get vaccinated in adulthood is up to the individual himself or herself. Parents are usually more risk-averse regarding their children's health than people are regarding their own health, so the factors affecting uptake are likely to be different. Aside from differences between healthcare professionals and the public over the importance of forgetting appointments, both groups generally agreed that availability of appointments and timing of appointments were barriers to receiving vaccinations - 58% and 56% respectively. Attitudes towards vaccinations from the adults surveyed were, on the whole, positive - although 24% of people agreed that vaccinations were mainly promoted by the healthcare system for pharmaceutical company profit, with 32% of 25-34 year olds believing this to be the case. Furthermore, understanding of vaccinations was fairly low (30.5% of adults believed that you can have too many vaccinations), and there was also a fairly low understanding of the concept of herd protection.

The attitudes towards vaccinations among older people were, in general, slightly more positive than those of younger adults. Older adults were less likely than younger generations to see or hear negative messages about vaccinations online compared to younger adults; this may be in part because they may be less likely than younger generations to use social media extensively. Older adults were more likely than any other age group to say that they see or hear positive messages in more traditional healthcare promotion settings, through healthcare professionals, and through national campaigns. This evidence suggests that more traditional methods of communication, and through healthcare settings, may be the most appropriate for improving uptake in older adults, where the online environment is of less significance. Over 50,000 cases of shingles occur in people aged 70 years and over each year in England and Wales; the finding that many felt there was a lack of information regarding the shingles vaccination may be related to the complex delivery of the vaccine, as well as a low awareness of the shingles vaccine and shingles itself.

The report looks at issues with particular vaccines among particular age groups, offering some suggestions for increased uptake. For example, tackling low uptake of the flu vaccine for working-age adults may require a multi-pronged approach: dispelling fears of side effects, promoting better understanding of the risk for the individual, and making access to the vaccine as easy as possible. For the pertussis vaccine, it appears that some pregnant women who do not receive the vaccination might not refuse it, but would want more information, discussion, and/or easier access to the vaccine beforehand. This may be because the vaccine is a fairly recent addition to the immunisation schedule for pregnant women, and there may be a sense that it is less familiar than other vaccines. Increasing awareness of why the vaccine is important in pregnancy and improving access to the vaccine may, therefore, be a priority. Encouraging trusted healthcare professionals, such as midwives, to reassure women that the vaccine is safe, effective, and important may help to tackle concerns around side effects and effectiveness.

Overall, the findings suggest that taking a multi-pronged approach to improving and maintaining uptake will be essential: reducing mistrust in the safety and efficacy of vaccines, increasing awareness of the value of vaccines, and improving access to vaccines. The report makes a number of recommendations aimed at a range of stakeholders, including social media platforms, health services, schools, and the press. For instance, RSPH suggests that:

• Efforts to limit health misinformation online and via social media should be increased, especially by social media platforms themselves.
• Responsibility of the press to share factual information about vaccines should be enforced by considering health impact when the Independent Press Standards Organisation (IPSO) Editor's Code is broken. (The survey found that many healthcare professionals believed that the media influenced parents' concerns and the uptake of the flu vaccine, for example, implying that the media did not give a balanced portrayal of the effectiveness of the vaccine and possible side effects.)
• Education on vaccines in schools should be increased and improved, especially in the Personal, Social and Health Education (PSHE) curriculum.
• Vaccinations should be offered in a more diverse range of locations, including at high-street pop-ups, gyms and workplaces, utilising the wider public health workforce.
• Health professionals should use the Making Every Contact Count (MECC) approach to ensure vaccine advice is delivered across the health system. For instance, midwives and health visitors work with parents during pregnancy and early childhood and have the chance to start conversations about immunisation at an early stage. School nurses also have important opportunities to interact with parents. These healthcare professionals are likely to be trusted by and accessible to parents and therefore be in a good position to provide valuable, targeted support.
• Reminder services should be improved and diversified, such as introducing birthday-style social media pop-ups for the 1 in 4 of those surveyed who find forgetting appointments a key barrier to getting vaccinated.