MMR social marketing project report

Commissioning Support for LondonPortland House, Stag Place, London SW1E 5RS

Increasing the uptake of MMR inLondonReport of social marketing project

November 2009

http://www.acropdf.com

Contents1 Introduction 31.1 Background 31.2 Objectives of the Social Marketing programme 31.3 Social Marketing Programme funding 31.4 Purpose of report 42 Methodology and approach 42.1 Audience insight with parents of high SEG 52.2 Pilot in-the-field activity with parents of lower SEG 63 Research findings 73.1 Insight with parents of high SEG 73.2 Recommendations from the research agency 84 Pilot-in-the-field activity 94.1 Creative development 94.2 Media planning 104.3 Media findings 104.3.1 MMR Landing Page 114.3.2 Text Service 114.3.3 Face to Face Activity 115 Evaluation 125.1 Evaluation Approach 125.2 Evaluation Findings 125.2.1 MMR take up by parents in low SEG audiences 125.2.2 Reactions to the MMR ‘1 in 10’ pilot 146 Process learnings 147 Recommendations 157.1 Develop an integrated strategy to increase MMR uptake 157.2 Infrastructure 167.3 Health practitioners 167.4 Public audiences 177.4.1 Existing audiences 177.4.2 Insight and development with new audiences 17Appendices 19Appendix 1: Examples of creatives 19Appendix 2: Media plan 19



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1 Introduction

1.1 BackgroundIn October 2008, the NHS London Executive Management Team (EMT) endorsed a proposalto establish a Childhood Immunisation project including a pan-London communicationprogramme and social marketing activity. The London Social Marketing Unit (LSMU) wascommissioned by NHS London to deliver the social marketing activity (LSMU joinedCommissioning Support for London in April 2009).Prior to this, LSMU commissioned University College London (UCL) to undertake a literaturereview 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 ofthe 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 programmeThe objectives set out at the project initiation were:

• To contribute to the increase from the current 75% London uptake figure for MMR andbring it closer to the 95% recommended coverage level required

• To prevent a measles epidemic in London by supporting measles Catch-Up campaigns asoutlined 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 arethe most effective

• To use the insight & findings to further plan interventions for 2009/10 strategy.

1.3 Social Marketing Programme fundingThe 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 ownexpense (see 2.2)



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• For clarity no funding for the communication pilot was provided by PCTs or Healthcare forLondon.

1.4 Purpose of reportThis document provides a summary of the project findings and was presented the LondonImmunisation Steering Group in September 2009. The project findings here are intended tobe used in conjunction with existing evidence to inform the practical development and designof future interventions. The document highlights (in italics) where the project findings differ orsupport 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 feasibilitystudy:, Sept 2008

A copy of an executive summary report is available from Commissioning Support for London.

2 Methodology and approachAn 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 schematicbelow shows the social marketing activities, from the initial literature review undertaken byUCL.



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The insight and evaluation elements of the MMR social marketing project used a qualitativeapproach. The Market Research Society (MRS) defines qualitative research as marketingand 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 ofquestioning and probing rather than providing information. The findings are based on analysisof responses and reflect participant’s perceptions, which may or may not reflect current policyor practice from the perspective of practitioners.Understanding audience’s relationship with issues through their experience and perceptionsis core to understanding how to influence behaviour towards a behavioural goal, in this caseincreasing the take up of MMR. It is intended that the findings of this project are used inconjunction with existing evidence to inform the design and delivery of future interventions.

2.1 Audience insight with parents of high SEGLSMU commissioned the research agency Burns and Company (via the Central Office ofInformation, COI) to deliver the insight project with parents from high SEG who choose not tovaccinate 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



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findings would inform the practical development and design of interventions andcommunications 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 ofMMR ‘refusers’ (now referred to as ‘doubters’), and to identify effective routes to behaviourchange. 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 ofinterventions 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 detailson the approach, recruitment and sample) is available from CSL. The findings were sharedwith health professionals at a Knowledge Transfer workshop on 17th June 2009 in London.

2.2 Pilot in-the-field activity with parents of lower SEGActivity was piloted targeting a mainstream audience (different to the ‘doubter’ audience) andspecifically 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 oneswere most effective in terms of reaching the target audience and driving parents withunvaccinated 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 2008



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The pilot was undertaken in 12 PCTs in London between 23 February to 3 April 2009 asfollows:

Funded PCTs Self-funded PCTs• Newham• Lewisham• Greenwich• Lambeth

• Barnet• Enfield• Hounslow• Brent

• Islington• Richmond & Twickenham

Working in conjunction with COI a creative brief was written and a pitch process was held inJanuary 2009. An agency (CMW) was selected to work on the creative development andmedia planning for the Social Marketing pilot and deliver a communications and interventionstrategy that would test different channels and reach the identified target audience.It was envisaged that this would include outdoor media activity to drive awareness inconjunction with direct marketing activities to drive uptake of MMR vaccination. There wasalso a community engagement element to be built in that would help to communicate directlywith specific hard to reach and BME audiences.An evaluation plan was written and a research agency (Burns and Company) wascommissioned to deliver the qualitative element of the pilot evaluation. The evaluation planproposed a quantitative input using MMR immunisation data being collected from LondonPCTs by the Health Protection Agency over a period that approximately coincided with thesocial marketing activity. However the quality of the MMR immunisation data was limited, andhas not provided a sufficiently robust input for this evaluation. As such, the evaluation isbased on the qualitative findings and response data.

3 Research findings3.1 Insight with parents of high SEGThe UCL study found that socio-economic status influences uptake of MMR, with low uptakein both low and higher SEG groups. It recommended further examination of why particularaudiences do or do not vaccinate. The NICE guidance found some evidence that uptake ofMMR has declined at a greater rate among children of more highly educated parents andamong those living in more affluent areas. The following is a summary of findings from theresearch agency of the insight project with parents from high SEG who choose not tovaccinate 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 reluctanceto accept MMR was the perceived link with autism. While the original Wakefield researchhas been discredited, years of media coverage and word of mouth reinforcement hasdriven their concerns. The NICE guidance notes that despite evidence from professionalsand 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 riskof 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 insteadthe safest option was to delay, to do nothing or, if they could afford it and felt it was rightfor their child, take the single jab route



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• Other barriers and concerns about MMR were minor in comparison with the fear ofautism. Some of the other barriers are post rationalisations, to justify their fears aboutautism, 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 aresult, this group actively avoid GPs/clinics as a source of information on MMR. The UCLstudy reported studies that identified a perception of HCPs as ‘agents of distrustedgovernment’

• Instead these parents’ influences were trusted personal contacts such as close family andfriends, particularly for first time mothers. The internet is a first port of call for researchingMMR, so it is important to have a presence with an MMR specific site. Organisationssuch as the National Autism Society, which are seen as independent of government, havecredibility in relation to information on MMR

• This audience want to hear an authority (ideally the NHS) tell them that research provesthat there is no link. They would like unequivocal certainty that there is no link betweenMMR and autism (although they do realise that nobody can give 100% guarantees aboutany vaccination)

• Attendance at nursery and school is a key trigger to re-consider vaccines for thisaudience, so interventions at this point would help their decision making. The NICEguidance makes recommendations on the contribution of nurseries, schools and furthereducation colleges to increasing the uptake of MMR. The actions include using schoolentry or transfer to a new college to check the vaccination status of children and youngpeople and explaining to parents why immunisation is important and providing informationin an appropriate format (such as Q&A sessions).

3.2 Recommendations from the research agencyThe brief to the research agency included them making recommendations to inform thepractical development and design of interventions to increase the uptake of MMR with thisaudience. It did not specify that this should reflect current government / Department ofHealth 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 linkbetween MMR vaccine and Autism have substance, which indicates a strong need toengage in a dialogue with this group. It will help to engage the attention and engagementof 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 simplydismiss the Wakefield study as being ‘inconclusive’ or ‘not proven’



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• 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 aretold 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 therecommendations presented in section 7. The NICE guidance recommends a range ofactions to reduce differences in the uptake of immunisations among children and youngpeople under 19 years. As part of a multifaceted, coordinated programme across differentsettings it recommends actions including tailoring information and invitations to differentcommunities and groups, using different settings to reach parents and young people, andensuring parents and young people have an opportunity to discuss any concerns they mighthave about an immunisation. It states that a note should be made of parents or young personexpress concerns about vaccination

4 Pilot-in-the-field activityPilot communications were developed and launched in March 2009, targeting mainstreamaudiences specifically parents of lower socio-economic groups (SEG) and ethnic minoritybackgrounds.

The aim of the pilot was to raise awareness of the risk of measles and the need for MMRamongst the target audience. The call to action was to visit your GP. Those who wereunregistered could text a code or visit the web site (www.mmrjab.com) for more information.

4.1 Creative developmentThe creative route aimed to address the challenge of a lack of awareness of the seriousnessof measles among parents and that parents compare measles to other less severe childhoodillnesses. It focused on the risks of measles, with the proposition that “1 in 10” children withmeasles ends up in hospital.

The creative aimed to engage with parents of young children, and to prompt them (mostlymothers) to have their children vaccinated with the MMR jab. The creative intended tohighlight the risks of their children catching measles, and in doing so change parents’ attitudetowards the MMR vaccine. The local branding aimed to make the issue relevant and local forparents.

The campaign comprised:

http://www.mmrjab.com



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• 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 inplaces that are hard to reach (e.g. Religious centres)

See Appendix 1 for examples of the creative.

4.2 Media planningThe media strategy for this pilot was to raise awareness within the target audience aboutmeasles 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 thegeographical areas where there would be a high propensity of the target audience. In additionto this, TGI (Target Group Index) data was used to map the media used by the targetaudiences.From this planning, outdoor sites, direct mail lists, door drop postcodes and insertpublications were booked. In addition, Face to Face activity was booked to focus in the areasof high representation of the target audience.Face to face activity has proved a successful approach in engaging people on different healthtopics, such as stopping smoking, and recruiting them into services. For the MMR Face toFace activity, brand ambassadors (BA’s) wearing a branded Measles uniform were briefed totalk with parents, members of the community and distribute MMR literature. The BAs werealso briefed to liaise with local community leaders to distribute MMR literature. They visitedlibraries, religious buildings, Mosques, Churches, community centres and local shops.Printed materials were translated into Urdu and Bengali as these were the most prevalentlanguages spoken in Newham PCT (the most diverse PCT in the pilot), with 16%+ populationof 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 otherssuch as Punjabi who tend to speak/understand English.The media plan is presented in Appendix 2.

4.3 Media findingsResponse data to the pilot activity was captured via 3 response mechanics – visits to theMMR web landing page, texts to a MMR specific text service and numbers of peopleengaging with the Face to Face activity. Response data gives a measure of the effectivenessof media, comparing the different media channels to each other. It does not reflect theeffectiveness of the media overall.



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4.3.1 MMR Landing PageA landing page was developed to support the MMR pilot. The objective was to support thecall to action on the MMR advertising materials, and to re-direct users through to the NHSimmunisation site to seek more information about the vaccine.

• Process: the landing page went live in March 2009 and initially had poor Search EngineOptimisation (SEO). It ranked extremely low on search engines which was a possiblereason for low response levels (Table1). From April 1st –30th, 2009 PPC (pay-per-click)was introduced at an additional cost which resulted in an increase in visits to the landingpage (Table 2).

Table 1: Website visits before PPC Table 2: Website visits after PPCDate Visits Date VisitsMarch 9 – 15, 2009 91 March 30 – April 5, 20009 339March 16 – 22, 2009 66 April 6 – 12, 2009 476March 23 – 29, 2009 48 April 13 – 19, 2009 478

• Results: website analysis found that 96% of users search for the site through Google. Thewords most commonly searched were Measles, MMR, Rubella, MMR Jab, Vaccine andMMR vaccine. As we are not able to measure the impact and awareness the increasednumber of hits had on the pilot, we feel that the investment was not maximised. We alsofeel that a landing page offers very little information and does not support the campaign orallow a mechanism to capture measurable data about the end user. Instead future activitycould make use of existing websites.

4.3.2 Text ServiceA text service was used as a call to action to measure the awareness and impact of the pilotactivity. This mechanism was used on all materials with the respected text word used onindividual pieces to measure which medium was most effective. The service was managedby COI.

• Process: The user texted the appropriate word to 64118 and received a text in replyasking for their post code. They would then be sent an additional text with the addressand phone number of the nearest GP offering MMR

• Results: The text service received 28 responses, with the most commonly used text wordbeing ‘surgery’. Due to the low response rates and the absence of a mechanism to assessthe limited results, this function did not deliver return on investment.

4.3.3 Face to Face ActivityThe 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 NHSimmunisation website to learn more about MMR vaccination. It targeted parents with childrenaged 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 parentsin locations with high footfall such as supermarkets (ie. Morrisons) and on high streets.They also liaised with local community organisations and groups. Brand Ambassadors



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asked approximately 1 in every 5 parents some short questions to collect headlineinformation about their views on MMR

• Results: the teams distributed more than 80,000 campaign leaflets including leaflets andposters. Of the 285 parents surveyed most agreed that measles is a serious disease andhalf felt the MMR vaccination was safe. Most parents had had their youngest childvaccinated with the first MMR, but fewer had had the second MMR vaccination.

5 Evaluation5.1 Evaluation Approach

The overall objective for this element of the social marketing activity was to evaluatereactions to the MMR pilot intervention in the trial areas from the perspective of parents in thetarget 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 theapproach, recruitment and sample) is available from CSL. The findings were presented at aKnowledge Transfer workshop on 17th June 2009 to health professionals in London.

5.2 Evaluation Findings5.2.1 MMR take up by parents in low SEG audiencesThe evaluation findings with the low SEG audience identified similarities and differences inviews 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 concernsabout the links to autism. Other barriers to MMR uptake included a lack of understanding ofthe 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 andrefutations 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’ audiencebecause they were not looking to update their knowledge or revisit their decision. Forthem the conversation was closed and decision made: they ignored communications



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asking them to make appointments. Many had other more immediate day to day prioritiessuch as housing and financial issues The NICE guidance found evidence that groups ofchildren and young people at risk of not being fully immunised included those notregistered with a GP, younger children from larger families, vulnerable children, such asthose whose families are travelers, asylum seekers or are homeless

• For this audience, the single jab option was neither desirable nor practical. They were lesslikely 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 higherSEG 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 amajor factor as identified by the UCL Literature Review. This differs from findings in theUCL study and NICE guidance. However the researchers qualified this finding by notingthat those with access issues can be harder to recruit for research (thus the research didnot engage with the very hard to reach). They did however find that single parent familiesand families living in temporary accommodation who participated appeared catered for byservices including Sure Start, health visitors and social services. The NICE guidancerecommends actions to improve access to vaccinations including extending clinic timesand ensuring enough immunisation appointments are available. It notes that logisticaldifficulties associated with large families and children not being in contact with primarycare services prevent children and young people from being up-to-date with theirvaccinations. Access was identified in the UCL study as a barrier to MMR uptake, both interms of access to information (knowing about the vaccination) and logistics (being able toget to locations where children can be vaccinated) .

The evaluation found that parents in the Asian community tended to be compliant when MMRwas explained to them. There was however an indication there were concerns in relation tothe vaccination amongst the Black/Afro Caribbean audience (although this was a smallsample). This might lead to more resistance to taking MMR and other vaccines. The UCLstudy found that ethnicity influenced the uptake of MMR and that differences within black andminority ethnic groups were apparent, with uptake rates higher amongst parents of Asianbackground. The NICE guidance highlights that children from minority ethnic groups andthose 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 healthservices, 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 thosewho were concerned about the autism link. Therefore, they needed the tools for tacklingconcerns about the perceived ‘risks’ of MMR. The NICE guidance recommends that allstaff involved in immunisation services are appropriately trained and that training shouldbe tailored to individual needs to ensure staff have the necessary skills and knowledge,for example, communications skills and the ability to answer questions about differentvaccinations

• Experience of data held by GP practices was that it was often inaccurate and PCTs werenot able to provide accurate data on who had been fully immunised, making it difficult to



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identify and contact the right people. The NICE guidance recommends that PCTs and GPpractices have a structured, systematic method for recording, maintaining and transferringaccurate information on the vaccination status of all children and young people.

5.2.2 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 forthose who do not have an ‘objection’ to MMR

• However the effectiveness of the creative idea was weakened by a number of factorsincluding:

o The ‘1 in 10’ line was not sufficiently motivating, and did not address theperception that there is a low risk of catching measles

o The link with MMR was not strong (with the focus on measles and no mentionof mumps or rubella) and did not address the perceived link between MMR andautism/disability

o There was insufficient explanation about why the second dose is importanto 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 andpractices. (The project team cascaded campaign information via PCT communicationteams however this point highlights that the information did not always reach practitionerswho were ‘public-facing’).

The evaluation brief included an objective that the research agency make developmentpointers 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 moreconfidence 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 learningsThe MMR project was commissioned and delivered in very short timescales, and thisimpacted on the time available to engage with partners and stakeholders in planning theproject and its workstreams.A review of the MMR social marketing project implementation process was initiated by ChrisHolmes, Director of London Social Marketing Unit, and Pratibha Datta, Director of PublicHealth at Redbridge PCT and London PH Lead for Childhood Immunisation in February2009. The review was undertaken by Julie George and Andrew Bailey with interviews with



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11 stakeholders involved in the commissioning and implementation of the social marketingMMR pilot activity.The implementation process had raised a number of issues regarding sign-off, stakeholderengagement and roles and responsibilities of the different organisation involved, and thereview sought to explore these and make recommendations for how a project should beimplemented 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 informationThe recommendations highlighted the value of applying a project management approach tofuture projects, including the role of a full social marketing brief, project plans and conveninga project initiation meeting. It also highlighted the importance of clear roles andresponsibilities, involvement and engagement of stakeholders and stakeholder management.The findings of the report were shared with the London Immunisation Steering Group.

7 RecommendationsA primary objective of the MMR social marketing pilot project was to use the insight andfindings to plan further interventions for the 2009/10 strategy. This section presents therecommendations for consideration and action by the London Immunisation Steering Group.Since the inception and delivery of the pilot project, immunisation has been identified by theNHS London Chief Executive a key area for attention across London due to poorperformance, with a specific reference to measles (in a letter to London PCT ChiefExecutives 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 PCTshave been intended to contribute towards closing the MMR vaccination gap in London.However, given the scale of the MMR immunisation deficit across London, a strategicapproach to meet the recommended 95% herd community is needed. The approach to dateoffers learnings and insight on interventions, however a strategy that combines a 3 yearapproach with a forecast of future investment is recommended.The insight findings with parents suggest that the perception of links between MMR andautism continue to be a primary concern, and as such a barrier to parents taking up MMR fortheir children. The erosion of this perception and resulting change in behaviour requires alonger term approach, given both the scale of the challenge and different audiencesrelationship to the issue.



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We also know that currently there is no complete picture of the MMR vaccination rates acrossLondon, and this is a key barrier to better understanding the scale of the issue and toeffectively targeting priority audiences. Work is in progress to improve the infrastructure andIT systems however this alone is unlikely to address the challenge.The London Social Marketing Unit’s experience of smoking cessation is that an integratedstrategy that continually evolves to reflect the growing understanding of audiences andeffectiveness of interventions can deliver improved return on investment and outcomes.Findings from this project suggest a Strategy for MMR needs to address the followingworkstreams:1. Infrastructure2. Healthcare practitioner audiences3. Public audiences.Our experience is that an integrated approach is needed to close the gap, rather than limitingactivity to a single workstream. The Immunisation Steering Group is requested to considerand action the allocation of resources across workstreams so as to optimise a Strategy’simplementation and outcomes.

7.2 Infrastructure

As outlined above there is an incomplete picture of MMR immunisation rates across Londonand London PCTs are transitioning to new IT systems. This has limited our understanding ofthe scale of the issue and importantly our ability to effectively target parents and families toincrease the uptake of MMR. The implementation of new IT systems and data cleansingneeds to continue in order to provide a fuller picture. However given the transient and mobilenature of London’s community, it is unlikely a totally complete picture will be realisable.

7.3 Health practitionersFindings from parents, specifically the ‘doubter’ audience, and healthcare practitionerssuggest that there a number of issues impacting on the uptake of MMR. These includehealthcare practitioners’ knowledge and skills in relation to MMR, specifically “how” healthpractitioners engage with parents on this topic and the information and resources available tothem 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 parentson MMR (the “how”). Healthcare practitioners need to be equipped with the skills toconfidently engage in a dialogue on MMR, including acknowledging parents’ concerns andfears. Training and development in motivational interviewing and interpersonal skills havesuccessfully been used in other areas.Some healthcare practitioners highlighted a lack of resources available to them to effectivelyengage with parents on the topic of MMR. A range of information and resources areavailable, many on the Department of Health website, however it appears that practitioners inthe field – including practice nurses, school nurses, health visitors and GPs - do not haveaccess to these or are not aware of them. Work needs to be undertaken to both effectively



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share these with practitioners and ensure that they meet the needs of different audiences ofparents (7.4).

7.4 Public audiences

The work of LSMU is to establish a long term plan based on a strategy informed by audienceinsight. The MMR project identified 2 priority audiences – (1) ‘doubters’, parents of high SEGand (2) parents of low SEG – and undertook specific activity with each of these. Therecommendations are based on findings for these existing audiences as well asrecommending activity to target new audiences. The Strategy to increase MMR uptake wouldinclude different audiences at different stages in the development cycle.

7.4.1 Existing audiencesA 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 offuture interventions. Ways to address parent’s concerns of the perceived links between MMRand autism need to be considered and developed. For both audiences interventions need toemphasise the long term and serious consequences of the 3 diseases, and develop theunderstanding 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 thediseases and the MMR vaccination, and address their concerns regarding the perceived linkwith autism. The findings show that parents in this audience can be hard to engage on thetopic of MMR once they have ‘made up their mind’. However, they have better contact withhealth practitioners than ‘doubters’ and this relationship is an opportunity to influence theirviews and behaviour in taking up MMR. We suggest this is supported by steady low-levelinterventions to shift perceptions and change behaviour.While this project did not identify access as a key barrier, other evidence highlights that thiscontinues to be an issue for some. As such, access needs to be addressed in developinginterventions as part of a Strategy.For ‘doubters’ –parents in high SEG - findings suggest that interventions designed to engagewith them in a way that acknowledges their concerns and addresses these with appropriateinformation could be effective. Creating opportunities for parents to consider MMR in settingsoutside of GP surgeries is one route. For example, a knowledgeable and confident healthpractitioner could offer informal group sessions. While a small sample, some parents whoparticipated in the insight project went on to get their children vaccinated. The opportunity todiscuss MMR in more depth and voice concerns or fears was what they needed in terms ofreassurance and was instrumental in changing their behaviour. A generic campaign focusingwould not be effective with this audience.

7.4.2 Insight and development with new audiencesInterventions with school-aged children and young people: there is a cohort of school agedchildren / young people who have not been immunised with MMR and continue to be at risk



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of catching measles, mumps and rubella. Older children / young people have fewerinteractions with health practitioners compared to their younger counterparts (0 – 5 yearolds). However, the school environment means that they are more likely to have exposure toother 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 notbeen successful in delivering increased MMR uptake rates. As such it is suggested thatinsight and development activity is undertaken with school-aged children, starting with ascoping exercise to define the audience and design the approach to test and evaluateinterventions.

For copies of the MMR Social Marketing Project Report and the UCL Literature Reviewplease go to the Project Documentation section on the London childhoodimmunisation project webpage:http://www.healthcareforlondon.nhs.uk/the-london-childhood-immunisation-project/

The NICE Guidance is available: http://guidance.nice.org.uk/PH21

http://www.healthcareforlondon.nhs.uk/the-london-childhood-immunisation-project/


http://guidance.nice.org.uk/PH21


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Appendices

Appendix 1: Examples of creatives

Appendix 2: Media plan

23.02 02.03 09.03 16.03 23.03 30.03 06.04 13.04 20.04CommunityCommunity pack & Face toface activityOutdoor advertisingBus sheltersPhone boxesDirect marketingInsertsBounty Direct MailDoor dropsWeb MMR Landing page


Documents

MMR social marketing project report