A strategy to increase childhood vaccination coverage
Executive summary
This is a strategy to address falling childhood vaccination rates in England, by making eligibility for government childcare funding contingent upon having received all age-appropriate vaccinations. Connecting vaccination requirements to entry into a social environment is consistent with promoting a collective responsibility around vaccination, as other countries have already done, and research suggests that a quasi-mandatory approach would be acceptable to UK parents and stakeholders. This will be part of a broader programme to increase childhood vaccination coverage, which includes a London-specific outreach programme, and an initiative to strengthen online expert voices (Macdougall, 2019). The problem of falling vaccination rates Seven vaccinations against 13 diseases are recommended for pre-school children (Figure 1) and are provided for free to UK residents through the NHS. Vaccination coverage needs to remain at 95% or above to provide sufficient ‘herd immunity’ to resist the spread of disease through a population. However, coverage for all routine childhood vaccinations fell in 2018/19 compared with the previous year (NHS Digital, 2019), continuing the downward trend that has been seen since 2013/14. While a few regions are reaching 95% coverage targets, most are not, and only one vaccination reached 95%
take-up (Appendix 1).
Figure 1. UK schedule of recommended pre-school vaccinations (Public Health England, 2020)
The primary causal theory for declining coverage in developed countries is vaccine hesitancy, which
is seen as having three components: complacency, convenience and confidence (MacDonald, 2015).
A research study in 1400 UK residents found that more than half expressed some vaccine hesitancy,
particularly uncertainty about the need for vaccinations and aversion to potential side effects, with
up to 4% being strongly resistant (Luyten, 2019). The World Health Organization (2019) rated vaccine
hesitancy as one of the top ten global health threats in 2019.
The main groups at risk are infants not yet old enough to be vaccinated, those who cannot be
vaccinated due to allergy or immune compromise, and children and adults who have missed out on
vaccinations. The recent measles outbreak in Samoa demonstrated how quickly undervaccination
can become a health emergency, with 2% of the population infected and 81 deaths in under 3
months (BBC News, 2019).
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Current strategy and opportunities for action
The government’s role is predominantly executed by NHS England and Public Health England (PHE).
Vaccination services are commissioned by NHS England through the Public Health Functions
Agreement, and PHE procures vaccines on behalf of GP practices, which are the main route for
access to pre-school vaccinations (National Audit Office, 2019).
Cross-sectoral involvement outside health is minimal. Local authorities may be involved in engaging
hard-to-reach groups within communities, and school immunisation teams are funded to deliver
routine vaccinations and catch-up for missed pre-school doses (National Audit Office, 2019).
UK vaccination coverage targets are set at 95%, in line with the WHO-recommended threshold, and
coverage data is published by NHS Digital every quarter. These reports allow NHS England to
performance manage contracts as well as guiding PHE and regional teams in their procurement and
local commissioning roles (National Audit Office, 2019).
In England, strategies to increase vaccination uptake have largely targeted GPs rather than parents.
Since 2001, GP practices have been eligible to receive payments if they meet immunisation targets
(Gostin, 2020), and local outreach initiatives and call/recall system improvements have shown some
success (Crocker-Buque, 2017). Additional incentives were added to the GP contract in 2019 for
MMR catch-up for 10-11 year olds, with practices receiving £5 per unvaccinated child, in return for
call/recall activity and engagement with school nursing services (NHS England, 2019).
In other countries, governments have used authority-based approaches (Hood, 1986) to make
vaccination mandatory for pre-school and/or school attendance. Enforcement approaches vary, from
needing to claim a vaccine exemption in the USA, to fining parents in Germany, fining childcare
facilities in Australia, or excluding unvaccinated children from school in Italy (Gostin, 2020).
Equivalent policies directed towards parents are currently absent in the UK.
The new Conservative majority government recognised the problem of falling vaccination coverage
and made a commitment to promote vaccination uptake within its manifesto (Conservative and
Unionist Party, 2019). With high political capital and several years until the next election cycle, there
is a policy window (Kingdon and Thurber, 1984), and the opportunity to introduce a second-order
policy change by using new instruments (Hall, 1993).
Promoting uptake in a vaccine-hesitant population: What works?
Despite a threefold increase in academic publications on the topic from 2007-2012 (Larson, 2014),
literature reviews have not revealed effective strategies to overcome vaccine hesitancy. However,
sermon-based (Bemelmans-Videc, 1998) educational approaches often deepened resistance (Dubé,
2015).
The degree of acceptable coercion for vaccination policies is hotly debated, in terms of the rights of
individuals versus the collective duty to society, though ethicists and lawmakers in various countries
have determined compulsory vaccination to be justifiable in the public interest (Giubilini, 2019;
Grzybowski, 2017). Countries create policy on a “continuum of coercion” (McCoy, 2019, p.825),
trying to balance the need to overcome passive noncompliance without being so coercive as to
produce active resistance.
Research in the UK did not find vaccine hesitancy to be associated with employment, socioeconomic
status, education, health status or health optimism (Luyten, 2019); this lack of clustering around
demographic factors favours broad-based rather than targeted measures. Quasi-mandatory
approaches to pre-school vaccination (‘quasi’ because opt-out or exemption is possible) have been
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found to be acceptable among UK parents and stakeholders (Adams, 2015). They consistently
preferred this over the ‘carrot’ (Bemelmans-Videc, 1998) of parental cash incentives, which were
seen as bribes (Adams, 2015).
Policy design
The proposed policy will make eligibility for government childcare funding contingent on having
received all age-appropriate vaccinations. This approach is based on withholding of government
treasure (Hood, 1986) and aims to overcome the ‘complacency’ aspects of vaccine hesitancy, as well
as attempting to tip the balance of ‘convenience’ in favour of vaccination.
The government’s Free Early Education Entitlement (FEEE) scheme (HM Government, 2020) offers
parents in England 15-30 free hours of childcare per week during term time for 3-4 year olds.1 All
parents are eligible for 15 hours per week, while 30 hours are available to parents working more
than 16 hours per week and with annual family income under £100,000. The national take-up of FEEE
is high at 94%, though this drops to 84% in London (NatCen Social Research, 2018).
Based on the current UK immunisation schedule, children should have received 13/15 of their
routine childhood vaccination doses by age 3 (Figure 1), making this age group ideally placed for a
policy intervention. Although the last two pre-school vaccine doses due at age 3 will not be directly
incentivised, prior attendances may have overcome vaccine hesitancy enough to promote uptake.
Timing and availability of GP appointments were cited by parents as barriers to vaccination (Royal
Society for Public Health, 2019), and existing GP incentives as well as this new parent-focused policy
should encourage both parties to work to overcome these challenges. Discussion between health
professionals and parents still needs to be an important part of the process, particularly where
hesitancy is related to ‘confidence’ issues. Vaccination exemptions would be permissible for medical
reasons or on a religious basis, but not for conscientious objection.
Implementation strategy
Despite some expected conflict around introduction of this policy, the government has control over
the services involved, meaning implementation is likely to be straightforward (Matland, 1995). The
public-facing website www.childcarechoices.gov.uk (HM Government, 2020) sets out FEEE eligibility
criteria, and the requirement for up-to-date vaccinations will be added. Enquiries are also made
directly to local authorities about the scheme (Local Government Association, 2019) and briefing
materials will be provided. A 9-month lead-in time to the policy will give parents time to take their
children for any missed vaccinations and avoid losing out on the allowance.
Parents apply for FEEE via an online form, which triggers an HMRC check of income status to
determine eligibility. With this referral functionality already in place, the front-end form and the
back-end processes can be modified to trigger a parallel vaccination check by the GP surgery. Placing
the burden of evidence on the practice rather than the parent avoids adding an additional barrier to
application, which could undermine both the vaccination programme and FEEE efforts. The GP
surgery’s effort should be offset by a reduction in the volume of proactive outreach they need to do
to achieve target coverage.
1
An FEEE option for disadvantaged 2-year-olds is also available, but is not included in this paper, as the time
point is less suited to a vaccination policy intervention and take-up is much lower than on the scheme for 3-4
year olds (NatCen Social Research, 2018).
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Policy framing will require careful planning through focus groups, to create messaging suitable not
only to those communicating it, but also to the receivers and the wider culture (Entman, 1993). The
evidence base around vaccine messaging is inconsistent, with a meta-analysis showing no significant
difference between loss-framed and gain-framed messaging in promoting vaccination uptake
(O’Keefe and Nan, 2012), though approaches that aim to correct information deficits often backfire
and should be avoided (Rossen, 2016).
Strengths and limitations
The high financial value of the childcare support that will be offered to vaccinated children suggests
this strategy is likely to be effective in its goal of increasing coverage, as well as being enforceable
and straightforward to monitor. Its strengths are that the timing of the intervention at age 3-4 is
optimal, falling after most vaccine doses should have been received; and eligibility for FEEE is broad,
with high national uptake. It also provides a coherent message across education and health, in terms
of vaccination as a societal duty when children go into group environments, to protect the most
vulnerable who have low immunity or cannot be vaccinated for medical reasons.
A key risk is the dependence on continuation of the FEEE scheme by the Department for Education. If
it were cancelled or restricted in scope, this would prevent the vaccination coverage goals being met
through this channel. Conversely, if adding a vaccination requirement dissuades childcare
applications, this would jeopardise the goal of the FEEE policy to increase workforce participation in
parents of young children (Treasury Committee, 2018) and may necessitate its uncoupling.
Other possible limitations are explored below, using a policy instrument analysis approach from
Althaus (2013).
Effectiveness: Parents working less than 16 hours a week are not eligible for FEEE, and some families
self-fund childcare or receive employer support instead. These children would be missed by the
policy. It is, however, still preferred to a universal policy targeting school age children, due to its
earlier intervention point and the ability for parents to choose to decline vaccination if they are
prepared to forgo the FEEE benefit. London has the lowest take-up of FEEE (84%; NatCen Social
Research, 2018), indicating the need for a supplementary initiative in the capital.
Efficiency: Whether benefits outweigh costs will partly depend on the degree of overlap between
the 94% of children who become enrolled in FEEE and the 5-10% of children (Appendix 1) who have
not yet received all vaccinations by age 3. The absence of data system linkages means this cannot be
determined prospectively, but empirical evidence is often limited ahead of policy decisions (Head,
2010) and post-launch data should be fed back into the policy cycle.
Appropriateness: This approach remains more permissive than the mandatory policies of other
developed countries, as scheme opt-out is possible and there is a route for medical and religious
exemptions. In spite of this, placing any conditions around vaccination on childcare will almost
certainly provoke backlash from a vocal minority who believe parental rights are being
compromised. This should be planned for and monitored, but should not change the policy direction
providing it does not negatively impact vaccination uptake.
Equity: By linking vaccination to a financial benefit, it must be considered whether a
disproportionate coercive pressure is placed on the poorest families who cannot afford to opt out of
childcare. A major study of vaccine uptake in Scotland found that deprivation was associated with
late vaccination rather than vaccine refusal, which is more linked to affluence (Friederichs, 2006),
providing some reassurance, though this should be reviewed post-launch.
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Workability: Experience in the USA suggests GPs may be put under pressure by parents to grant
vaccine exemptions based on preferences rather than medical or religious grounds (Gostin, 2020).
This sidestepping of the policy will be hard to eliminate completely. Nonetheless, for those in whom
‘complacency’ or ‘convenience’ are the causes of hesitancy, the effort involved in gaining an
exemption should still provide a net benefit in vaccination uptake.
Evaluation
Vaccine coverage data are published quarterly and are relatively complete, offering near real-time
assessment of the impact of interventions. Data on FEEE applicants and their vaccination status will
also be available for analysis. The main indicators of success would be:
•
•
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An increase in national coverage of all vaccination doses for children under 3 within 12 months
of the policy start date.
No significant drop in the number of first-time applicants to the childcare scheme, or a shortterm drop that rebounds to pre-policy levels within 12 months (to allow for delayed start of
childcare support due to vaccination catch-up)
>80% rate of successful repeat applications among those rejected from the FEEE due to
incomplete vaccine coverage, both as an indicator that the incentive is translating into action to
vaccinate children, and that it is not adversely impacting the goals of the FEEE scheme.
The above data will be evaluated annually for the first 5 years of the policy. Vaccine-preventable
infectious disease incidences are not included as primary indicators, given the sporadic nature of
outbreaks, and the well-documented efficacy of vaccinations making coverage levels an appropriate
surrogate measure.
Although devolved UK nations have comparable vaccination schedules and quarterly data reporting,
each nation sets its own strategy. If this England-based strategy is not mirrored in devolved nations,
a difference-in-differences analysis at 12 and 24 months after introduction of this policy will also be
carried out, using Scotland as a comparator country.
The drivers of, and effectiveness of responses to, hesitancy remain poorly understood, and it would
be of concern if this intervention deepened resistance, as other strategies have done in the past
(Dubé, 2015). Any impact – positive or negative – on vaccine hesitancy should be evaluated by
repeating the UK survey by Lutyen (2019) using the same methodology, 24 months after strategy
implementation. Qualitative research should also explore any pressure on GP services, both in terms
of the verification process and requests for exemptions.
Conclusion
With vaccination coverage falling in England, more needs to be done to protect the most
immunologically vulnerable in society. Connecting a vaccination requirement to childcare support
stands to be effective, in view of the FEEE scheme’s reach and the age group. Although some
opposition is to be expected, there are indications that this policy would be more acceptable to
parents and stakeholders than mandatory or financial inducement approaches. This strategy is both
proportionate and timely, and complements GP-led efforts.
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References
Adams, J. et al. (2015) Effectiveness and acceptability of parental financial incentives and quasimandatory schemes for increasing uptake of vaccinations in preschool children: systematic
review, qualitative study and discrete choice experiment. Health Technology Assessment. 19
(94), 1–176.
Althaus, C. et al. (2013) ‘Chapter 6. Policy instruments’, in The Australian Policy Handbook. Sydney:
Allen & Unwin. pp. 90–100.
BBC News (2019) Samoa lifts state of emergency over measles epidemic. 29 December. Available
from: https://www.bbc.co.uk/news/world-asia-50938250 (Accessed 20 January 2020).
Bemelmans-Videc, M.-L. et al. (1998) Carrots, Sticks, and Sermons: Policy Instruments and Their
Evaluation. New Jersey: Transaction Publishers.
Conservative and Unionist Party (2019) Get Brexit Done, Unleash Britain’s Potential: The Conservative
and Unionist Party Manifesto 2019. Available from: https://vote.conservatives.com/our-plan
(Accessed 8 January 2019).
Crocker-Buque, T. et al. (2017) Interventions to reduce inequalities in vaccine uptake in children and
adolescents aged