Vaccination in England: a review of why business as usual is not enough to maintain coverage

Abstract

BackgroundThe vaccine system in England underwent radical changes in 2013 following the implementation of the Health and Social Care Act. There have since been multi-year decreases in coverage of many vaccines. Healthcare professionals have reported finding the new system fragmented and challenging. This study aims to produce a logic model of the new system and evaluate the available evidence for interventions to improve coverage.MethodsWe undertook qualitative document analysis to develop the logic model using process evaluation methods. We performed a systematic review by searching 12 databases with a broad search strategy to identify interventions studied in England conducted between 2006 and 2016 and evaluated their effectiveness. We then compared the evidence base to the logic model.ResultsWe analysed 83 documents and developed a logic model describing the core inputs, processes, activities, outputs, outcomes and impacts of the new vaccination system alongside the programmatic assumptions for each stage. Of 9,615 unique articles, we screened 624 abstracts, 45 full-text articles, and included 16 studies: 8 randomised controlled trials and 8 quasi-experimental studies. Four studies suggest that modifications to the contracting and incentive systems can increase coverage, but changes to other programme inputs (e.g. human or capital resources) were not evaluated. Four multi-component intervention studies modified activities and outputs from within a GP practice to increase coverage, but were part of campaigns or projects. Thus, many potentially modifiable factors relating to routine programme implementation remain unexplored. Reminder/recall systems are under-studied in England; incentive payments to adolescents may be effective; and only two studies evaluated carer information.ConclusionsThe evidence base for interventions to increase immunisation coverage in the new system in England are limited by a small number of studies and by significant risk of bias. Several areas important to primary care remain unexplored as targets for interventions, especially modification to organisational management.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-6228-5) contains supplementary material, which is available to authorized users.

Understanding vaccine acceptance and demand—and ways to increase them

“…At the individual level (capability and motivation), some interventions have been shown to increase vaccination uptake, e.g. health workers providing face-to-face clear, balanced information about vaccination risks and benefits ([32, 34, 35]; see Table 1). In addition, many experimental studies have assessed how different types of messages or interventions affect people’s perceptions about vaccination and intentions to vaccinate.…”

“…applying motivational interviewing techniques and providing a clear provider recommendation for vaccination [25, 42, 45, 46]Health workers being an example (e.g. confirm they have vaccinated themselves/their children) to their patients [11, 25] Motivation Evidence-based decision aid for supporting informed decision-making about vaccination [42]Health workers providing face-to-face clear, balanced information about vaccination risks and benefits and the childhood vaccination schedule [33–35]Incentives for children/adolescents [30], caregivers [33] or vaccinators, e.g. reimbursement for health-care providers who vaccinate [35]…”

Adherence to the paediatric immunisation schedule in England

“…Such efforts should involve educational, clinical, and policy interventions targeted at improving the infrastructure used for vaccine delivery, training health care professionals, and educating parents to raise awareness about the importance of timely vaccinations. [3] , [25] , [50] , [51] , [52] Also strengthening the relationship between the health care providers and particularly parents with several children and families with a lower educational level or lower socioeconomic status is an approach that should be considered. [26] , [53] , [54] , [55] …”

Model-Based Planning and Delivery of Mass Vaccination Campaigns against Infectious Disease: Application to the COVID-19 Pandemic in the UK

“…In addition to the demand stratification, this step requires data on staff working hours per day, vaccine administration rate, and patients vaccinated per day (UK target). Herein, we assume that staff should work at least six hours a day and spend ten min vaccinating each patient, including screening and consent activities [59][60][61]. Following the UK government vaccination campaign ambitions, we assume a daily vaccination rate of 500,000 patients per day across the UK [62][63][64].…”