How To Increase Mmr Uptake

Transcription

1 Increasing the uptake of MMR in London Report of social marketing project November 2009

2 Contents 1 Introduction Background Objectives of the Social Marketing programme Social Marketing Programme funding Purpose of report 4 2 Methodology and approach Audience insight with parents of high SEG Pilot in-the-field activity with parents of lower SEG 6 3 Research findings Insight with parents of high SEG Recommendations from the research agency 8 4 Pilot-in-the-field activity Creative development Media planning Media findings MMR Landing Page Text Service Face to Face Activity 11 5 Evaluation Evaluation Approach Evaluation Findings MMR take up by parents in low SEG audiences Reactions to the MMR 1 in 10 pilot 14 6 Process learnings 14 7 Recommendations Develop an integrated strategy to increase MMR uptake Infrastructure Health practitioners Public audiences Existing audiences Insight and development with new audiences 17 Appendices 19 Appendix 1: Examples of creatives 19 Appendix 2: Media plan 19

3 1 Introduction 1.1 Background In October 2008, the NHS London Executive Management Team (EMT) endorsed a proposal to establish a Childhood Immunisation project including a pan-london communication programme and social marketing activity. The London Social Marketing Unit (LSMU) was commissioned by NHS London to deliver the social marketing activity (LSMU joined in April 2009). Prior to this, LSMU commissioned University College London (UCL) to undertake a literature review and intervention feasibility study on how to increase the uptake of MMR. The study, delivered in September 2008, found that social-demographic factors influence the uptake of the MMR vaccine and pointed to following groups in which intervention was most needed: Parents in low socio-economic group (SEG) where access to services was cited as a barrier Parents in high SEG making a conscious decision not to have their children vaccinated with MMR Parents from ethnic minority backgrounds (BME) are less likely to immunise. The UCL findings informed the social marketing approach proposed and delivered by LSMU (see section 2 below). 1.2 Objectives of the Social Marketing programme The objectives set out at the project initiation were: To contribute to the increase from the current 75% London uptake figure for MMR and bring it closer to the 95% recommended coverage level required To prevent a measles epidemic in London by supporting measles Catch-Up campaigns as outlined in the Chief Medical Officer s (CMO) letter to all PCTs Increase the proportion of children under the age of 5 with completed MMR immunisation To gain key insight into the attitudes and drivers that will trigger behaviour change within identified priority audiences and establish which interventions and communications are the most effective To use the insight & findings to further plan interventions for 2009/10 strategy. 1.3 Social Marketing Programme funding The programme of work undertaken by LSMU was funded as follows: The initial UCL study was funded by LSMU in full All other activity was funded from NHS London Public Health budget, with the exception of 2 Primary Care Trusts who funded the communication pilot in their locality at their own expense (see 2.2) 3

4 For clarity no funding for the communication pilot was provided by PCTs or Healthcare for London. 1.4 Purpose of report This document provides a summary of the project findings and was presented the London Immunisation Steering Group in September The project findings here are intended to be used in conjunction with existing evidence to inform the practical development and design of future interventions. The document highlights (in italics) where the project findings differ or support current evidence, specifically referencing the following documents: NICE public health guidance 21 Reducing differences in the uptake of immunizations (including targeted vaccines) among children and young people aged under 19 years, Sept 2009 UCL How can MMR uptake be increased? A literature review and intervention feasibility study:, Sept 2008 A copy of an executive summary report is available from. 2 Methodology and approach An approach was designed to deliver findings by undertaking two workstreams: Audience insight with parents in high socio-economic group, SEG (referred to as doubters ) Piloting and evaluating in the field activity with parents in lower SEG. A further description of these workstreams is outlined below in 2.1 and 2.2. The schematic below shows the social marketing activities, from the initial literature review undertaken by UCL. 4

5 The insight and evaluation elements of the MMR social marketing project used a qualitative approach. The Market Research Society (MRS) defines qualitative research as marketing and social research conducted whereby: the basic methodology involves techniques which seek to reach understanding through observation, dialogue and evocation, rather than measurement where the data collection process involves open-ended, non-directive techniques (not structured questionnaires) where the data analysis output is descriptive and not statistical. This approach enables us to understand attitudes and perceptions through a process of questioning and probing rather than providing information. The findings are based on analysis of responses and reflect participant s perceptions, which may or may not reflect current policy or practice from the perspective of practitioners. Understanding audience s relationship with issues through their experience and perceptions is core to understanding how to influence behaviour towards a behavioural goal, in this case increasing the take up of MMR. It is intended that the findings of this project are used in conjunction with existing evidence to inform the design and delivery of future interventions. 2.1 Audience insight with parents of high SEG LSMU commissioned the research agency Burns and Company (via the Central Office of Information, COI) to deliver the insight project with parents from high SEG who choose not to vaccinate their children. From DH tracking studies we know this audience, known as refusers or doubters, makes up between 5 to 10% of parents. It was intended that the 5

6 findings would inform the practical development and design of interventions and communications for the 09/10 strategy to increase the take up of MMR among this group. The overall objectives for the project were to understand the motivations and behaviour of MMR refusers (now referred to as doubters ), and to identify effective routes to behaviour change. More specifically, the objectives were: To understand the factors influencing the decision not to vaccinate To understand the sources of information and influence on this decision To understand what would encourage them to reconsider their decision not to have their children vaccinated? The purpose of the research was to inform the practical development and design of interventions to increase the take up of MMR amongst refusers. A summary of the findings is presented in section 3 below and the full report (including details on the approach, recruitment and sample) is available from CSL. The findings were shared with health professionals at a Knowledge Transfer workshop on 17 th June 2009 in London. 2.2 Pilot in-the-field activity with parents of lower SEG Activity was piloted targeting a mainstream audience (different to the doubter audience) and specifically parents of lower socio-economic groups (SEG) and ethnic minority backgrounds. The strategy was to test a number of different media channels in the field to learn which ones were most effective in terms of reaching the target audience and driving parents with unvaccinated children to have the MMR vaccination. The pilot aims were: To test communication methods as part of the MMR social marketing project To engage with parents with small children To change parent s attitude towards having their child vaccinated. To encourage parents to get their children vaccinated with the MMR vaccination The following criteria were used to select the PCTs taking part in the pilot activity: % of 5 year olds with 0 MMR dose and % of 2 year olds with 1 dose Health Protection Agency (HPA) Informatics data extracted from compatible GP systems HPA modeling of susceptible children and uptake Confirmed cases of measles in

7 The pilot was undertaken in 12 PCTs in London between 23 February to 3 April 2009 as follows: Funded PCTs Newham Lewisham Greenwich Lambeth Barnet Enfield Hounslow Brent Self-funded PCTs Islington Richmond & Twickenham Working in conjunction with COI a creative brief was written and a pitch process was held in January An agency (CMW) was selected to work on the creative development and media planning for the Social Marketing pilot and deliver a communications and intervention strategy that would test different channels and reach the identified target audience. It was envisaged that this would include outdoor media activity to drive awareness in conjunction with direct marketing activities to drive uptake of MMR vaccination. There was also a community engagement element to be built in that would help to communicate directly with specific hard to reach and BME audiences. An evaluation plan was written and a research agency (Burns and Company) was commissioned to deliver the qualitative element of the pilot evaluation. The evaluation plan proposed a quantitative input using MMR immunisation data being collected from London PCTs by the Health Protection Agency over a period that approximately coincided with the social marketing activity. However the quality of the MMR immunisation data was limited, and has not provided a sufficiently robust input for this evaluation. As such, the evaluation is based on the qualitative findings and response data. 3 Research findings 3.1 Insight with parents of high SEG The UCL study found that socio-economic status influences uptake of MMR, with low uptake in both low and higher SEG groups. It recommended further examination of why particular audiences do or do not vaccinate. The NICE guidance found some evidence that uptake of MMR has declined at a greater rate among children of more highly educated parents and among those living in more affluent areas. The following is a summary of findings from the research agency of the insight project with parents from high SEG who choose not to vaccinate their children (see 2 for approach details): This audience accepted other vaccinations (they were not immunisation rejecters as such) but had specific concerns about MMR. The primary concern driving their reluctance to accept MMR was the perceived link with autism. While the original Wakefield research has been discredited, years of media coverage and word of mouth reinforcement has driven their concerns. The NICE guidance notes that despite evidence from professionals and the DH, some parents remained concerned about the link to autism For these parents the risks of vaccinating their children with MMR (and the perceived risk of autism) far outweigh the perceived risks associated with measles, mumps and rubella. They therefore felt unable to take the decision to have their child vaccinated and instead the safest option was to delay, to do nothing or, if they could afford it and felt it was right for their child, take the single jab route 7

8 Other barriers and concerns about MMR were minor in comparison with the fear of autism. Some of the other barriers are post rationalisations, to justify their fears about autism, and these may dissipate once the fear has been addressed. They included: Measles was not perceived to be a common disease nowadays, which undermined the urgency of getting vaccinated Concern about taking 3 vaccines in 1 being too much for a young immune system and side effects and, for some, egg allergy For these parents, their experience of health professionals in relation to MMR tends to be non committal or dismissive. GPs are not perceived as impartial advisors on MMR. As a result, this group actively avoid GPs/clinics as a source of information on MMR. The UCL study reported studies that identified a perception of HCPs as agents of distrusted government Instead these parents influences were trusted personal contacts such as close family and friends, particularly for first time mothers. The internet is a first port of call for researching MMR, so it is important to have a presence with an MMR specific site. Organisations such as the National Autism Society, which are seen as independent of government, have credibility in relation to information on MMR This audience want to hear an authority (ideally the NHS) tell them that research proves that there is no link. They would like unequivocal certainty that there is no link between MMR and autism (although they do realise that nobody can give 100% guarantees about any vaccination) Attendance at nursery and school is a key trigger to re-consider vaccines for this audience, so interventions at this point would help their decision making. The NICE guidance makes recommendations on the contribution of nurseries, schools and further education colleges to increasing the uptake of MMR. The actions include using school entry or transfer to a new college to check the vaccination status of children and young people and explaining to parents why immunisation is important and providing information in an appropriate format (such as Q&A sessions). 3.2 Recommendations from the research agency The brief to the research agency included them making recommendations to inform the practical development and design of interventions to increase the uptake of MMR with this audience. It did not specify that this should reflect current government / Department of Health policy. The following recommendations were made: Medical professionals and the NHS need to acknowledge parents (high SEG audience) concerns and address them directly with balanced, impartial, evidence based information. The silence of the NHS is taken as an indication that the arguments for a potential link between MMR vaccine and Autism have substance, which indicates a strong need to engage in a dialogue with this group. It will help to engage the attention and engagement of this audience if the discussions and communications can start from their point of view For the NHS to spell out in unequivocal terms that there is no link with autism. Ideally, this should be backed by research, but at least some statistics, and it should not simply dismiss the Wakefield study as being inconclusive or not proven 8

9 To open up dialogue between this audience and health professionals (GPs and Nurses) and re-establish trust in relation to MMR. They want a discussion but instead feel they are told what to do when they ask about MMR. If the autism issue is addressed, other messages that will help to prompt reappraisal include: A clear medical rationale for why 3 in 1 is better than single jabs (other than cost and convenience) The potentially serious and long term consequences of measles, mumps and rubella not just for young children, but for when they are adults Comparisons with other countries where MMR is given The likelihood of catching measles (particularly if there are local outbreaks) The responsibility to protect your child and other children prior to going to nursery or school MMR can be taken at any stage, to suit the child and the mother. The insight findings and recommendation have been considered in developing the recommendations presented in section 7. The NICE guidance recommends a range of actions to reduce differences in the uptake of immunisations among children and young people under 19 years. As part of a multifaceted, coordinated programme across different settings it recommends actions including tailoring information and invitations to different communities and groups, using different settings to reach parents and young people, and ensuring parents and young people have an opportunity to discuss any concerns they might have about an immunisation. It states that a note should be made of parents or young person express concerns about vaccination 4 Pilot-in-the-field activity Pilot communications were developed and launched in March 2009, targeting mainstream audiences specifically parents of lower socio-economic groups (SEG) and ethnic minority backgrounds. The aim of the pilot was to raise awareness of the risk of measles and the need for MMR amongst the target audience. The call to action was to visit your GP. Those who were unregistered could text a code or visit the web site ( for more information. 4.1 Creative development The creative route aimed to address the challenge of a lack of awareness of the seriousness of measles among parents and that parents compare measles to other less severe childhood illnesses. It focused on the risks of measles, with the proposition that 1 in 10 children with measles ends up in hospital. The creative aimed to engage with parents of young children, and to prompt them (mostly mothers) to have their children vaccinated with the MMR jab. The creative intended to highlight the risks of their children catching measles, and in doing so change parents attitude towards the MMR vaccine. The local branding aimed to make the issue relevant and local for parents. The campaign comprised: 9

10 Outdoor media: 6 sheet (billboards) posters and phone boxes in high footfall in areas Local press inserts Door drops: targeted by postcode via Royal Mail Direct mail to Bounty mailing list, targeted at low SEG homes using Acorn profile MMR website landing page Face to face activity to engage with local communities and advocate MMR: these were deployed in areas of high footfall (such as shopping centres and high streets) and in places that are hard to reach (e.g. Religious centres) See Appendix 1 for examples of the creative. 4.2 Media planning The media strategy for this pilot was to raise awareness within the target audience about measles and to reinforce action via direct marketing and community face to face activities. Within PCTs, Acorn (a socio-demographic mapping tool) was used to identify the geographical areas where there would be a high propensity of the target audience. In addition to this, TGI (Target Group Index) data was used to map the media used by the target audiences. From this planning, outdoor sites, direct mail lists, door drop postcodes and insert publications were booked. In addition, Face to Face activity was booked to focus in the areas of high representation of the target audience. Face to face activity has proved a successful approach in engaging people on different health topics, such as stopping smoking, and recruiting them into services. For the MMR Face to Face activity, brand ambassadors (BA s) wearing a branded Measles uniform were briefed to talk with parents, members of the community and distribute MMR literature. The BAs were also briefed to liaise with local community leaders to distribute MMR literature. They visited libraries, religious buildings, Mosques, Churches, community centres and local shops. Printed materials were translated into Urdu and Bengali as these were the most prevalent languages spoken in Newham PCT (the most diverse PCT in the pilot), with 16%+ population of both Urdu and Bengali speakers in Newham followed by Hounslow with 4% of each. These communities have lower levels of English language and literacy, compared others such as Punjabi who tend to speak/understand English. The media plan is presented in Appendix Media findings Response data to the pilot activity was captured via 3 response mechanics visits to the MMR web landing page, texts to a MMR specific text service and numbers of people engaging with the Face to Face activity. Response data gives a measure of the effectiveness of media, comparing the different media channels to each other. It does not reflect the effectiveness of the media overall. 10

11 4.3.1 MMR Landing Page A landing page was developed to support the MMR pilot. The objective was to support the call to action on the MMR advertising materials, and to re-direct users through to the NHS immunisation site to seek more information about the vaccine. Process: the landing page went live in March 2009 and initially had poor Search Engine Optimisation (SEO). It ranked extremely low on search engines which was a possible reason for low response levels (Table1). From April 1 st 30 th, 2009 PPC (pay-per-click) was introduced at an additional cost which resulted in an increase in visits to the landing page (Table 2). Table 1: Website visits before PPC Table 2: Website visits after PPC Date Visits Date Visits March 9 15, March 30 April 5, March 16 22, April 6 12, March 23 29, April 13 19, Results: website analysis found that 96% of users search for the site through Google. The words most commonly searched were Measles, MMR, Rubella, MMR Jab, Vaccine and MMR vaccine. As we are not able to measure the impact and awareness the increased number of hits had on the pilot, we feel that the investment was not maximised. We also feel that a landing page offers very little information and does not support the campaign or allow a mechanism to capture measurable data about the end user. Instead future activity could make use of existing websites Text Service A text service was used as a call to action to measure the awareness and impact of the pilot activity. This mechanism was used on all materials with the respected text word used on individual pieces to measure which medium was most effective. The service was managed by COI. Process: The user texted the appropriate word to and received a text in reply asking for their post code. They would then be sent an additional text with the address and phone number of the nearest GP offering MMR Results: The text service received 28 responses, with the most commonly used text word being surgery. Due to the low response rates and the absence of a mechanism to assess the limited results, this function did not deliver return on investment Face to Face Activity The Face to Face Activity aimed to inform local communities of the seriousness of measles, signpost people to the free immunisation service, and encourage parents to visit the NHS immunisation website to learn more about MMR vaccination. It targeted parents with children aged 1 5 and/or 6 18 years. Process: Brand Ambassadors with knowledge of local communities engaged with parents and community leaders in multiple locations across 8 PCT s (Newham, Lewisham, Barnet, Enfield, Islington, Richmond, Twickenham and Hounslow). Teams engaged with parents in locations with high footfall such as supermarkets (ie. Morrisons) and on high streets. They also liaised with local community organisations and groups. Brand Ambassadors 11

12 asked approximately 1 in every 5 parents some short questions to collect headline information about their views on MMR Results: the teams distributed more than 80,000 campaign leaflets including leaflets and posters. Of the 285 parents surveyed most agreed that measles is a serious disease and half felt the MMR vaccination was safe. Most parents had had their youngest child vaccinated with the first MMR, but fewer had had the second MMR vaccination. 5 Evaluation 5.1 Evaluation Approach The overall objective for this element of the social marketing activity was to evaluate reactions to the MMR pilot intervention in the trial areas from the perspective of parents in the target audience and healthcare professionals. More specifically, the objectives were: To explore reactions to the 1 in 10 materials in terms of communication, comprehension, motivation, relevance, and impact (insofar as this is assessable via qualitative research) To explore reactions to the different media used and understand which was effective To understand what approaches were most effective with this audience To understand the barriers to the MMR vaccination and what would encourage them to get their children vaccinated To assess response to the communications mix amongst Healthcare Professionals (HCPs) To provide guidance for developing the communications plan. A summary of the findings is presented below and the full report (including details on the approach, recruitment and sample) is available from CSL. The findings were presented at a Knowledge Transfer workshop on 17 th June 2009 to health professionals in London. 5.2 Evaluation Findings MMR take up by parents in low SEG audiences The evaluation findings with the low SEG audience identified similarities and differences in views towards MMR and the 3 diseases compared to the high SEG ( or doubters ) audience. Importantly, the similarities across both audiences included a distrust of MMR and concerns about the links to autism. Other barriers to MMR uptake included a lack of understanding of the importance of the second MMR dose and of the seriousness of the 3 diseases. In contrast the key differences between the 2 audiences included: Compared to MMR doubters this audience (low SEG) was less likely to have researched MMR in detail. Therefore, they had not necessarily heard the counter arguments and refutations of the Wakefield report Instead they were more likely to be informed and swayed by media stories and hearsay. Based on this, they made a decision to avoid the perceived risk by not taking up MMR They could potentially be harder to influence and persuade than the doubter audience because they were not looking to update their knowledge or revisit their decision. For them the conversation was closed and decision made: they ignored communications 12

13 asking them to make appointments. Many had other more immediate day to day priorities such as housing and financial issues The NICE guidance found evidence that groups of children and young people at risk of not being fully immunised included those not registered with a GP, younger children from larger families, vulnerable children, such as those whose families are travelers, asylum seekers or are homeless For this audience, the single jab option was neither desirable nor practical. They were less likely to take the view that it is better to wait until their child is older However they had better contact with and respect for GPs and nurses than the higher SEG audience who lacked trust in relation to the issue of MMR For the participants in this project, lack of access to health services did not seem to be a major factor as identified by the UCL Literature Review. This differs from findings in the UCL study and NICE guidance. However the researchers qualified this finding by noting that those with access issues can be harder to recruit for research (thus the research did not engage with the very hard to reach). They did however find that single parent families and families living in temporary accommodation who participated appeared catered for by services including Sure Start, health visitors and social services. The NICE guidance recommends actions to improve access to vaccinations including extending clinic times and ensuring enough immunisation appointments are available. It notes that logistical difficulties associated with large families and children not being in contact with primary care services prevent children and young people from being up-to-date with their vaccinations. Access was identified in the UCL study as a barrier to MMR uptake, both in terms of access to information (knowing about the vaccination) and logistics (being able to get to locations where children can be vaccinated). The evaluation found that parents in the Asian community tended to be compliant when MMR was explained to them. There was however an indication there were concerns in relation to the vaccination amongst the Black/Afro Caribbean audience (although this was a small sample). This might lead to more resistance to taking MMR and other vaccines. The UCL study found that ethnicity influenced the uptake of MMR and that differences within black and minority ethnic groups were apparent, with uptake rates higher amongst parents of Asian background. The NICE guidance highlights that children from minority ethnic groups and those whose first language is not English may also be vulnerable. As part of the evaluation the views of healthcare professionals were sought and included: Health professionals felt that there were particular problems with the second dose of MMR. Often, the first dose was taken up because mothers were still in touch with health services, but they may lose touch, forget, or not see the importance of the second dose Nurses and health visitors did not feel well equipped to deal with questions from those who were concerned about the autism link. Therefore, they needed the tools for tackling concerns about the perceived risks of MMR. The NICE guidance recommends that all staff involved in immunisation services are appropriately trained and that training should be tailored to individual needs to ensure staff have the necessary skills and knowledge, for example, communications skills and the ability to answer questions about different vaccinations Experience of data held by GP practices was that it was often inaccurate and PCTs were not able to provide accurate data on who had been fully immunised, making it difficult to 13

14 identify and contact the right people. The NICE guidance recommends that PCTs and GP practices have a structured, systematic method for recording, maintaining and transferring accurate information on the vaccination status of all children and young people Reactions to the MMR 1 in 10 pilot The 1 in 10 visual attracts attention and raises concern about measles, and the messages about the long term consequences of measles are shocking and compelling for those who do not have an objection to MMR However the effectiveness of the creative idea was weakened by a number of factors including: o The 1 in 10 line was not sufficiently motivating, and did not address the perception that there is a low risk of catching measles o The link with MMR was not strong (with the focus on measles and no mention of mumps or rubella) and did not address the perceived link between MMR and autism/disability o There was insufficient explanation about why the second dose is important o The direct mail piece was not understood (by consumers or practitioners) o The posters lacked the key information about the long term, serious consequences of measles Practitioners held similar views, adding that the PCT immunisation teams had not been alerted to the campaign or equipped with the materials to distribute to nurses and practices. (The project team cascaded campaign information via PCT communication teams however this point highlights that the information did not always reach practitioners who were public-facing ). The evaluation brief included an objective that the research agency make development pointers to inform future communications plans. These included: Nurses, health visitors and GPs need to be equipped with training, information and materials to help them address questions about MMR. This will give them more confidence when explaining it to parents with objections A specific leaflet for MMR, which addresses all the concerns Emphasis of the long term, serious consequences of measles, mumps and rubella; why the second dose is important and strengthen the link to MMR. 6 Process learnings The MMR project was commissioned and delivered in very short timescales, and this impacted on the time available to engage with partners and stakeholders in planning the project and its workstreams. A review of the MMR social marketing project implementation process was initiated by Chris Holmes, Director of London Social Marketing Unit, and Pratibha Datta, Director of Public Health at Redbridge PCT and London PH Lead for Childhood Immunisation in February The review was undertaken by Julie George and Andrew Bailey with interviews with 14

15 11 stakeholders involved in the commissioning and implementation of the social marketing MMR pilot activity. The implementation process had raised a number of issues regarding sign-off, stakeholder engagement and roles and responsibilities of the different organisation involved, and the review sought to explore these and make recommendations for how a project should be implemented in the future. The review covered 5 major themes in relation to the MMR project: Clarity of purpose Project timing and planning Accountability and responsibilities Stakeholder engagement Expert contact and information The recommendations highlighted the value of applying a project management approach to future projects, including the role of a full social marketing brief, project plans and convening a project initiation meeting. It also highlighted the importance of clear roles and responsibilities, involvement and engagement of stakeholders and stakeholder management. The findings of the report were shared with the London Immunisation Steering Group. 7 Recommendations A primary objective of the MMR social marketing pilot project was to use the insight and findings to plan further interventions for the 2009/10 strategy. This section presents the recommendations for consideration and action by the London Immunisation Steering Group. Since the inception and delivery of the pilot project, immunisation has been identified by the NHS London Chief Executive a key area for attention across London due to poor performance, with a specific reference to measles (in a letter to London PCT Chief Executives in June 2009). 7.1 Develop an integrated strategy to increase MMR uptake The social marketing pilot activity and other MMR immunisation initiatives in London PCTs have been intended to contribute towards closing the MMR vaccination gap in London. However, given the scale of the MMR immunisation deficit across London, a strategic approach to meet the recommended 95% herd community is needed. The approach to date offers learnings and insight on interventions, however a strategy that combines a 3 year approach with a forecast of future investment is recommended. The insight findings with parents suggest that the perception of links between MMR and autism continue to be a primary concern, and as such a barrier to parents taking up MMR for their children. The erosion of this perception and resulting change in behaviour requires a longer term approach, given both the scale of the challenge and different audiences relationship to the issue. 15

16 We also know that currently there is no complete picture of the MMR vaccination rates across London, and this is a key barrier to better understanding the scale of the issue and to effectively targeting priority audiences. Work is in progress to improve the infrastructure and IT systems however this alone is unlikely to address the challenge. The London Social Marketing Unit s experience of smoking cessation is that an integrated strategy that continually evolves to reflect the growing understanding of audiences and effectiveness of interventions can deliver improved return on investment and outcomes. Findings from this project suggest a Strategy for MMR needs to address the following workstreams: 1. Infrastructure 2. Healthcare practitioner audiences 3. Public audiences. Our experience is that an integrated approach is needed to close the gap, rather than limiting activity to a single workstream. The Immunisation Steering Group is requested to consider and action the allocation of resources across workstreams so as to optimise a Strategy s implementation and outcomes. 7.2 Infrastructure As outlined above there is an incomplete picture of MMR immunisation rates across London and London PCTs are transitioning to new IT systems. This has limited our understanding of the scale of the issue and importantly our ability to effectively target parents and families to increase the uptake of MMR. The implementation of new IT systems and data cleansing needs to continue in order to provide a fuller picture. However given the transient and mobile nature of London s community, it is unlikely a totally complete picture will be realisable. 7.3 Health practitioners Findings from parents, specifically the doubter audience, and healthcare practitioners suggest that there a number of issues impacting on the uptake of MMR. These include healthcare practitioners knowledge and skills in relation to MMR, specifically how health practitioners engage with parents on this topic and the information and resources available to them to do so. To re-establish trust between parents and healthcare practitioners in relation to MMR, attention needs to be given to the nature of healthcare practitioners engagement with parents on MMR (the how ). Healthcare practitioners need to be equipped with the skills to confidently engage in a dialogue on MMR, including acknowledging parents concerns and fears. Training and development in motivational interviewing and interpersonal skills have successfully been used in other areas. Some healthcare practitioners highlighted a lack of resources available to them to effectively engage with parents on the topic of MMR. A range of information and resources are available, many on the Department of Health website, however it appears that practitioners in the field including practice nurses, school nurses, health visitors and GPs - do not have access to these or are not aware of them. Work needs to be undertaken to both effectively 16

17 share these with practitioners and ensure that they meet the needs of different audiences of parents (7.4). 7.4 Public audiences The work of LSMU is to establish a long term plan based on a strategy informed by audience insight. The MMR project identified 2 priority audiences (1) doubters, parents of high SEG and (2) parents of low SEG and undertook specific activity with each of these. The recommendations are based on findings for these existing audiences as well as recommending activity to target new audiences. The Strategy to increase MMR uptake would include different audiences at different stages in the development cycle Existing audiences A mix of interventions targeting different audiences is needed rather than a 1 size fits all approach. We would not recommend a roll-out of the 1 in 10 campaign in its current form, however the lessons learnt from the pilot should be taken into account in the planning of future interventions. Ways to address parent s concerns of the perceived links between MMR and autism need to be considered and developed. For both audiences interventions need to emphasise the long term and serious consequences of the 3 diseases, and develop the understanding that it is never too late to vaccinate and that 2 doses of MMR are needed. For parents of low SEG audience there is an ongoing need to raise awareness of the diseases and the MMR vaccination, and address their concerns regarding the perceived link with autism. The findings show that parents in this audience can be hard to engage on the topic of MMR once they have made up their mind. However, they have better contact with health practitioners than doubters and this relationship is an opportunity to influence their views and behaviour in taking up MMR. We suggest this is supported by steady low-level interventions to shift perceptions and change behaviour. While this project did not identify access as a key barrier, other evidence highlights that this continues to be an issue for some. As such, access needs to be addressed in developing interventions as part of a Strategy. For doubters parents in high SEG - findings suggest that interventions designed to engage with them in a way that acknowledges their concerns and addresses these with appropriate information could be effective. Creating opportunities for parents to consider MMR in settings outside of GP surgeries is one route. For example, a knowledgeable and confident health practitioner could offer informal group sessions. While a small sample, some parents who participated in the insight project went on to get their children vaccinated. The opportunity to discuss MMR in more depth and voice concerns or fears was what they needed in terms of reassurance and was instrumental in changing their behaviour. A generic campaign focusing would not be effective with this audience Insight and development with new audiences Interventions with school-aged children and young people: there is a cohort of school aged children / young people who have not been immunised with MMR and continue to be at risk 17

18 of catching measles, mumps and rubella. Older children / young people have fewer interactions with health practitioners compared to their younger counterparts (0 5 year olds). However, the school environment means that they are more likely to have exposure to other children with the diseases, and are at greater risk. In the insight with the doubter audience we found that school entry is a trigger for them to re-consider vaccines. However, to date, school based interventions targeting children and young people have not been successful in delivering increased MMR uptake rates. As such it is suggested that insight and development activity is undertaken with school-aged children, starting with a scoping exercise to define the audience and design the approach to test and evaluate interventions. For copies of the MMR Social Marketing Project Report and the UCL Literature Review please go to the Project Documentation section on the London childhood immunisation project webpage: The NICE Guidance is available: 18

19 Appendices Appendix 1: Examples of creatives Appendix 2: Media plan Community Community pack & Face to face activity Outdoor advertising Bus shelters Phone boxes Direct marketing Inserts Bounty Direct Mail Door drops Web MMR Landing page