Dr Clare French et al – Written Evidence (CVX0033)
Introduction
We are a group of academic researchers focused on inter-disciplinary vaccine research at the University of Bristol. Our work spans multiple disciplines including: population health, behavioural science, evaluation, evidence synthesis, mathematical modelling, clinical vaccinology, immunology, infectious diseases and health economics. We are supported by major infrastructure awards: NIHR Health Protection Research Unit in Evaluation and Behavioural Science and NIHR Health Protection Research Focus Award in Vaccines & Immunisation. We are also supported by several research grants, for example an EU Horizon 2020 grant that funds the JITSUVAX project to develop tools to understand and tackle vaccine misinformation. We have a strong track record of producing evidence that has informed UK vaccine policy including the introduction of vaccines for meningococcal serotype B in 2015 and varicella in 2026 (Christensen 2014, Marlow 2025). In addition, we have contributed to policy reports including “Vaccination in the UK: Access, Uptake and Equity” by the Royal College of Paediatrics and Child Health (RCPCH) Commission on Immunisation, 2024-25.
Authors
Brief summary
This submission draws on our experience and the findings of work we have undertaken including:
Our key findings and recommendations are as follows:
Main submission
Question 3. What would be the best ways to improve childhood vaccination coverage and reduce disparities?
3.1 Here we draw on findings from our comprehensive systematic review of randomised controlled trials conducted in high and upper middle income countries evaluating the effectiveness of interventions to increase vaccine uptake (Davies 2025, Davies 2026), alongside other sources of evidence.
3.2 For childhood vaccinations, increasing accessibility by offering extended vaccination opportunities (e.g. extended clinic hours) was effective (Davies 2026). This may be especially helpful for busy parents, particularly those with multiple children, who may find it difficult to schedule and attend appointments. The finding aligns with the UK RCPCH commissioned report which underscores the need for easier access to vaccination services. Our discussions with a group of parents and carers of babies and young children highlighted some of the challenges faced in accessing routine vaccinations including difficulties in booking appointments and inflexible appointment times, further emphasising the importance of addressing access barriers. Additional details on these discussions are provided in our answer to question 8. Providing payments to cover costs (e.g. travel costs) and the use of decision aids were also beneficial (Davies 2026). Targeting affordability barriers for families on low incomes may help address disparities in vaccine uptake.
3.3 Further insights are provided by a complimentary systematic review (currently under peer-review with Vaccine) focused on interventions to improve pre-school vaccination timeliness, defined as receipt of specified vaccines within a limited and specified time period following the age at which vaccines are due. There was limited evidence from a small number of studies of a potential beneficial effect of combination vaccines, communication training, quality improvement, education and schedule change interventions. There were no eligible studies on interventions to improve access to vaccination services or address appointment scheduling challenges. We recommend further high-quality research to evaluate interventions aimed at improving timeliness of pre-school vaccinations.
3.4 For adolescents and young adults (where interventions could be aimed at the adolescent/young adult, their caregiver, or both), how information around vaccination is delivered was important. For example, there were beneficial effects of personal delivery formats (e.g. text, email), and where interactive communication methods were used, and human interaction worked less well than automated approaches (Davies 2026). These findings suggest efforts could be targeted towards co-developing effective communication strategies for this group, perhaps exploring the use of new interactive technologies. Involving community members in communicating about vaccines can also improve uptake. Members of the diverse public involvement group we worked with emphasised the importance of involving both community members and healthcare professionals in supporting people to get vaccinated, highlighting that trust is essential (McGrath 2025).
3.5 Whilst such evidence synthesis work provides broad insights into the most promising types of interventions, the findings need to be integrated with local-level insights to develop strategies that are effective for local populations. We also note the importance of working in partnership with local community organisations and members to deliver interventions tailored to their needs. Adequate and sustainable resourcing for interventions to improve vaccine uptake is essential - short-term initiatives should not divert funding from core healthcare services. General practice (GP) surgeries are best placed to deliver the complex routine pre-school childhood vaccination schedule for most families. There is a need to develop a more nuanced understanding of which aspects of access interventions work best in GP settings, including provider perspectives on feasibility and sustainability within resources available.
Question 4. What are the strengths and weaknesses of the evidence base on childhood vaccination coverage; the drivers of the decline in coverage; and how to improve coverage and reduce disparities?
4.1 Our evidence synthesis work (outlined in our response to question 3; Davies 2025 and Davies 2026), demonstrates that there is a substantial and growing body of scientific literature on interventions to increase vaccine uptake. However, in our review, two-thirds of studies were conducted in the United States which has a different healthcare model to the UK. There were a limited number of studies from the UK, and these tended to be somewhat outdated. There were few studies on interventions to improve access to childhood vaccinations, and for other types of interventions (e.g. motivational interviewing) there were none at all. Embedding robust evaluation into the roll-out of new interventions and policies is vital to strengthen the evidence base, particularly in the UK context. Importantly, we noted a lack of studies incorporating analyses of intervention effectiveness by ethnicity and other socio-economic factors. Such information is essential to help address inequities in vaccination.
4.2 We identified a notable lack of economic data for interventions that have been trialled. Of the total 268 studies included in our systematic review, only 37 reported economic data. Reporting of cost components was inconsistent which means it was not possible to draw any firm conclusions about the comparative cost-effectiveness of different intervention strategies (Hamashima 2025). Future research should collect and report relevant economic data to enable informed decision-making around which interventions to implement given limited resources.
Question 8. How accessible are childhood vaccination services, both for the general population and for people in under-vaccinated groups? What are the main barriers to making childhood vaccination services more accessible for all, and how could those barriers be overcome?
8.1 For our ongoing project ‘Improving Access to Childhood Vaccination’ we are working with vaccination providers, commissioners, and communities to identify barriers and co-produce practical, sustainable solutions to make childhood vaccinations in GP settings more accessible for all families. Our initial discussions with parents and carers of babies and young children in Bristol identified some key access barriers and potential solutions. To address the challenge of arriving at the GP surgery for a vaccination appointment at a specific time practices could consider offering vaccination appointment ‘windows’ rather than specific timed appointments. To ensure families feel safe and comfortable when attending vaccination appointments practices should create a welcoming and reassuring environment. This includes ensuring waiting areas have enough space to accommodate buggies, and providing comfortable seating where parents can feed and soothe children after vaccinations. Difficulties reaching GP practices by phone were an issue - expanding online appointment booking could help address this. Automated pre-booking of vaccination appointments, as used by some practices, may be beneficial provided that clear information is given about the purpose of each appointment (e.g. which vaccinations will be offered) to avoid confusion.
8.2 We are carrying out a qualitative study ‘Changes to Childhood Vaccines Study’ to understand barriers and facilitators to uptake of the MMRV vaccine following the changes to the vaccine schedule introduced in January 2026. To date, we have interviewed 15 parents, primarily belonging to underserved population groups, who have children eligible for the new vaccination schedule. Some parents were positive about the schedule changes, particularly the opportunity to protect their child against chickenpox without having to source the varicella vaccine privately. However, other parents reported reservations. In some cases, these concerns appeared to stem from perceptions of the MMRV vaccine being new or chickenpox being a mild disease. Other parents appeared unsure of vaccination programmes in general, which often related to increased mistrust since the COVID-19 pandemic. Inflexible appointment booking systems in GP settings also prevented or delayed some families getting their children vaccinated. Parents reflected on their unmet information needs about the MMRV vaccine. Channels of information should utilise trusted sources, including community engagement, and be accessible in different formats (digital resources, short videos, leaflets, face-to-face discussions with healthcare professionals). Parents also suggested improving access by delivering the MMRV vaccine in different settings (e.g. nurseries, playgroups, pharmacies).
8.3 The majority of young women receive human papillomavirus (HPV) vaccine in the school setting. However, we showed that access to HPV vaccination could be improved by provision in community settings, such as catch-up clinics and GP surgeries (Fisher 2021). This may benefit young women who may have had anxieties about being vaccinated without a parent or carer present, or did not attend school on the day of the vaccination session. Community provision of the HPV vaccine also appeared to reduce substantial inequalities in uptake among young women educated in alternative education provider settings. The reasons for this are unclear, but could relate to their lower school attendance, complex behavioural and physical health needs, or perceptions of safety of vaccination in the school setting due to interactions with other medical treatments.
Question 9. What is the influence of public attitudes on childhood vaccination coverage? What are the key barriers to strengthening public trust and confidence in childhood vaccination, and how could those barriers be overcome?
9.1 From our conversations with parents and carers of babies and young children in Bristol as part of our ‘Improving Access to Childhood Vaccination’ project we found a lack of detail on vaccination (including side effects) from NHS sources made people seek information online including social media, which may be inaccurate. Some parents had used AI to answer their questions, which contradicted answers given by the nurse, creating confusion. Particularly in the first few months after birth, this can be a vulnerable time for parents, when interaction with staff is important for building trust. Some parents felt judged when they chose not to give a particular vaccine to their child and then felt worried about going for future vaccinations, and several felt rushed at appointments and that staff did not listen to concerns. Parents wanted easier access to information about what the vaccines are protecting against, potential side effects of the vaccine and aftercare (e.g. whether to bring Calpol to appointments) ahead of vaccination appointments. For those going through this for the first time, a walkthrough video of what to expect at the appointment could offer reassurance.
9.2 For HPV vaccination, parental decision-making depended on the potential for harm to their adolescent children and anticipated regret (Fisher 2024). Distrust around the safety of vaccines was apparent, with parents referring to misinformation circulating on social media and perceptions that key information about side-effects was not explicitly provided within official circulated information. As widely trusted sources of vaccine information, healthcare professionals could play an important role in dispelling misconceptions and providing reassurance to parents. Parents may be unwilling to raise concerns or not know that vaccinations are approaching. Healthcare professionals could help reassure parents by making reference to upcoming vaccinations at routine checkups.
9.3 Decision-making among vaccine-hesitant, ethnically diverse parents can be negatively influenced by an overall lack of knowledge, as well as understanding about the diseases and associated harms that the HPV vaccine protects against, anxieties relating to the false perception that there are serious side-effects, and their perceptions of their adolescent child’s future exposure (Fisher 2024). Communication materials about the HPV vaccine should highlight the benefits of protection against cancer to increase parents’ motivation to protect their adolescent child; provide accurate convincing information in relation to the excellent safety profile; and emphasise the importance of providing HPV vaccine at the recommended age, all alongside communicating the universality and commonality of HPV infection.
9.4 A website to help teenagers and parents find out about the HPV vaccine in schools is now available. The HPV Inform website will contribute to overcoming HPV vaccine misinformation and empowering families with access to information they need to make decisions which can help protect their teenage children’s health. The website, co-created by our researchers at the University of Bristol alongside families and key stakeholders, has information and helpful resources for young people, parents/carers and professionals to find out: i) what HPV is and the different illnesses it can cause; ii) how the HPV vaccine protects young people, and it’s safety and side effects; iii) how and where to get the vaccine; and iv) tips to help young people getting the vaccine at school. The website includes resources created by the project team as part of the EDUCATE and COMMUNICATE research studies. As well as resources that young people and parents can access directly, there are also lesson plans which could be used by school staff or immunisation teams to provide information to young people in school, for example in PHSE lessons, tutor time or assembly.
Question 11. How effectively are core and outreach childhood vaccination services delivered, including delivery through different providers and in different settings? How could service delivery be made more effective to help improve coverage and reduce disparities?
11.1 Qualitative research with parents has identified that the main reasons young children do not receive the influenza vaccine are “a lack of convenient access to vaccination opportunities and flu vaccination being a low priority for busy parents” (Price 2022). The importance of improving accessibility has been highlighted in research with parents (Davey 2025) and in the Chief Medical Officer’s annual report. In addition, some parents have religious or strongly held beliefs opposing the vaccine or a strongly held view that their child does not need a flu vaccine (Paterson 2018). Higher vaccination rates are found in primary schools where the barrier of access and parent time is removed, demonstrating that child flu vaccination rates can be higher. Our public engagement with 17 parents and 6 early years staff through our NIHR EARLY study has shown interest in and acceptability for vaccination in early years settings and the benefit for busy parents.
11.2 Supplementary vaccination in early years settings (nursery schools, day nurseries and pre-schools) has been piloted in Wales (see response to question 18, paragraph 18.1 for more details). We are aware of further pilots in England and Wales over the last two years (e.g. in County Durham, Hywel Ddh and Thames Valley) which have been funded in England through one-off Integrated Care Board funding. Each have had different delivery models (practice nurses, health protection nurses and school-aged immunisation teams) and have indicated promise at extending reach, but without independent research evaluation. Research is needed to establish how effective different early years delivery models are alongside general practice, whether they reduce inequalities and whether they are cost-effective.
Question 12. What is the influence of data systems on childhood vaccination coverage (including for inviting families for vaccinations, sharing data about vaccinations, and monitoring coverage)? What are the main barriers to the development and deployment of effective data systems, and how could those barriers be overcome?
12.1 An issue, common to all routinely collected data, is the possibility of data input errors and missing data. For example, in a HPV vaccine study, to minimise bias from inclusion of this data, we excluded almost 5% of the data as the information related to school was out-of-date (Fisher 2021). Overall, our dataset identified 8% of young women belonging to a minority ethnic group. This compares with nationally reported figures indicating 30% of young people attending secondary schools in the intervention areas belong to a non-white ethnic group.
Question 13. What is the influence of the vaccination workforce and the wider healthcare workforce on childhood vaccination coverage? How could the workforce be effectively trained and strengthened to help improve coverage and reduce disparities?
13.1 Healthcare professionals are highly important for encouraging vaccine uptake because of the trust they hold among parents and the opportunities they have for conversations with hesitant parents, as per a 2025 UKHSA survey. Our research with healthcare professionals found they were frequently unprepared for vaccine conversations with patients, and welcomed training to build their confidence especially to deal sensitively with misinformed beliefs about vaccines (Holford 2024). We have also tested interventions that can successfully train healthcare professionals to communicate well with patients and encourage vaccine uptake in their capacity as trusted messengers (Fasce 2025, Holford 2026a, Holford 2026b). These findings are also based on the EU-funded JITSUVAX project.
13.2 The curriculum coverage of basic vaccinology is highly variable across UK medical, nursing and allied-health professional undergraduate degrees and postgraduate training programmes. To help bridge this gap, we have contributed to the development of e-learning programmes designed for different healthcare students and qualified professionals such as ‘Wiser Immuniser’ by the European Society of Paediatric Infectious Diseases. We also led development of ‘Vaccines in Practice’ by the RCPCH (also accredited by Royal College of Nurses, and Royal College of General Practitioners). While there is evidence that these initiatives have been popular, there has been limited funding available to evaluate their impact and iterate their design.
Question 14. What is the influence of the wider public, community and voluntary sectors (including schools) on childhood vaccination coverage? How could the NHS work more effectively with the wider public, community and voluntary sectors (including schools) to help improve coverage and reduce disparities?
14.1 For HPV vaccination, provision in the UK within the school setting free at the point of delivery has overcome financial and access barriers identified in other settings (Fisher 2014). The requirement for parental consent is accompanied by varying degrees of commitment from school staff and nurses when seeking consent from more ‘hard to reach’ groups (Ferrer 2016). Some young women contributed to decision-making about the HPV vaccine and exercised some autonomy by persuading their parents to take them to the GP if they missed a session, while others avoided being vaccinated by throwing away information or consent forms. These issues may also be relevant to the MenACWY and Td/IPV school-based vaccination programmes in the UK.
14.2 Emerging findings from our realist evaluation suggest that community organisations can play a crucial role in addressing MMRV vaccine hesitancy, particularly by building trust and facilitating more meaningful engagement with communities who are often underserved by traditional health services. However, this impact is highly context dependent. Community-led approaches appear to be most effective when they are locally embedded, draw on existing relationships and networks, and are supported (rather than directed) by health systems. In contrast, where interventions are perceived as externally imposed or insufficiently aligned with community priorities, their ability to influence trust and uptake is more limited. These findings highlight the importance of not only involving community organisations, but doing so in ways that are authentic, sustained, and responsive to local context.
Question 15. What is the influence of the media environment on childhood vaccination coverage? What would be the best ways to support confidence and to address misinformation and disinformation about childhood vaccination in the media environment?
15.1 Dis/misinformation about vaccines is one contributor to public attitudes, as exposure to misinformation has been shown to have a negative impact on attitudes and intentions to vaccinate (Loomba 2021). A reason why misinformation is likely to shape attitudes is because it tends to target existing psychological vulnerabilities, known as “attitude roots”, which are things like fears, identity needs, sense of belonging, worldviews and ideologies. This makes the misinformation highly compelling and believable. The JITSUVAX project at Bristol (https://jitsuvax.info) conducted a systematic review of anti-vaccination arguments and found they associate with 11 underpinning attitude roots that motivate negative attitudes towards vaccination (Fasce 2023; see also JITSUVAX public learning resource for healthcare professionals). Attitude roots act as a barrier to changing vaccine attitudes, but it is possible to work with them to improve vaccine attitudes through communication that demonstrates empathy and alignment with attitude roots (Holford 2024). An intervention called the Empathetic Refutational Interview was developed and tested to structure conversations that deal with vaccine misinformation. This has been successfully trialled with healthcare professionals in the UK, France, Germany, Finland, and Romania, allowing them to counter the negative influence of mis- and dis-information spread in the media through conversations with patients, as sources who are more trusted than social media. In a study with Romanian GPs that looked at their communication about the HPV and flu vaccine with hesitant patients, training GPs to use the Empathetic Refutation technique resulted in greater improvements in vaccine attitudes and willingness and higher post-consultation vaccine appointment bookings relative to an untrained control group (Fasce 2025).
Question 16. What other key barriers are there to improving childhood vaccination coverage and reducing disparities? What would be the best ways to address them?
16.1 For HPV vaccination, the content of communication materials should emphasise HPV-related diseases and the protection offered against these, universality of health benefits by gender, and the effectiveness of the HPV vaccine and vaccination programme (Fisher 2024). Highlighting the potential benefit of prevention of HPV-related cancer by inclusion of the story of a cancer survivor may help increase parents’ motivation to vaccinate their adolescent children. Future communication materials should be developed in different languages to ensure that parents who do not speak English as their first language are not excluded from the decision-making process.
16.2 Our study examined parental information needs during decision-making about the HPV vaccine for their adolescent children, from the perspective of vaccine hesitant, ethnically diverse parents (Fisher 2024). Anxieties related to the potential for serious, long-term side-effects (e.g. fertility issues, developmental delays) appeared to negatively overshadow the protection offered against developing HPV-related cancers. Stigma associated with protection against a sexually transmitted infection did not always negatively influence parental decision-making, but misunderstandings about the importance of vaccination during early adolescence could influence parents to delay vaccination of their adolescent children.
16.3 Implementation of new consent procedures (parental verbal consent plus adolescent self-consent) appeared to overcome trends for decreasing uptake of HPV vaccine (Fisher 2020). Local policy change to consent procedures that allowed parents to consent verbally and adolescents to self-consent overcame some of the barriers to vaccination of young women belonging to families less likely to respond to paper-based methods of gaining consent and at greater risk of developing cervical cancer (Fisher 2020).
16.4 As the majority of parents who could be contacted provided verbal consent for HPV vaccination, the data imply that the absence of a signed parental consent form cannot be assumed to mean the parent does not want their daughter to have the vaccine (Fisher 2021). Not all parents could be contacted by the immunisation team on the day of the vaccination session. Provision of additional resources to contact families ahead of the vaccination session could help reduce the proportion of families who are not contacted and help ensure that their daughter receives the HPV vaccine if they wish.
16.5 Expanding consent procedures for the schools-based HPV vaccination programme to include parental telephone consent was broadly welcomed by the immunisation nurses, parents, and young women in our study. The requirement for young women to confirm that they had discussed vaccination with their parents, and that vaccination would not cause difficulties at home, meant adolescent self-consent was rare in this age-group. Greater understanding of the barriers to uptake outside of the mainstream school-based sessions is needed to further address inequalities in uptake (Audrey 2021). However, unresolved issues in relation to adolescent self-consent include public and professional perceptions of young people’s rights and abilities to take responsibility for decisions affecting their health, and concerns about the impact of self-consent on relationships both within families and between professionals and the families they serve.
Question 18. What can the UK Government learn about improving childhood vaccination coverage in England from Scotland, Wales, Northern Ireland, and/or other comparable countries?
18.1 Supplementary vaccination in early years settings (nursery schools, day nurseries and pre-schools) has been piloted in Wales. In 2018 health visitors and school nurses delivered the LAIV for three-year olds attending nursery schools in one area of Wales alongside the existing GP programme (Harris 2023). The pilot found uptake increased from 41% to 71%, with a reduction in inequalities of uptake (gap reduced from 17.4% to 10.3-13.4% over two years). Research is needed to establish how effective different early years delivery models are alongside general practice, whether they reduce inequalities and whether they are cost-effective.
18.2 For the nasally administered live attenuated influenza vaccine (LAIV), the United States Food and Drug Administration gave approval for a Supplemental Biologics License for self- or caregiver administration. A recent systematic review found self-administered LAIV was preferred by patients and appeared to have comparable safety and effectiveness to administration by a healthcare professional (Jhaveri 2025). This evidence suggests that England should review the learning from the US and consider approval within the Human Medicines Regulations 2012 and training requirements for vaccinators for self-administration or administration of LAIV by a parent or early years staff to a child.
22 April 2026