NHS Birmingham and Solihull: addressing MMR vaccine hesitancy

Overview

Birmingham and Solihull developed a targeted programme of community engagement and communications to identify and overcome vaccine hesitancy among some ethnic and religious groups, which resulted in increased understanding and uptake of the MMR vaccine.

Key benefits and outcomes

• Increase of over 6,000 MMR vaccinations over the course of the outbreak.
• 21 per cent more MMR vaccinations achieved overall in 2024 than in 2023.
• Targeted communications and marketing campaigns led directly to increased uptake of MMR vaccination.
• There has been a smaller, shorter rise in MMR cases in 2025, as learning from the 2023-24 outbreak has designed the 2025 response. 

What the system faced

In October 2023, Birmingham and Solihull (BSol) experienced a surge in measles cases and later that winter, UK Health Security Agency (UKHSA) declared a national incident. 

Community engagement highlighted concerns and lower uptake among some ethnic and religious groups in Birmingham and Solihull, with high levels of misinformation as well as distrust of healthcare settings and government messages. Strong concerns were also identified around the disproven link between autism and vaccinations, as well as a lack of awareness of porcine-free versions of MMR vaccines.

What the system did

In December 2023 the BSol system partners convened an incident management team (IMT) structure to oversee the governance and joint response to the emerging outbreak. 

The IMT partners established a responsive governance structure including cells covering data and intelligence; communications; engagement; immunisations and vaccinations; education and a clinical advisory group. 

IMT partners included Solihull Metropolitan Borough Council, BSol ICB, Birmingham City Council Public Health, UKHSA, NHS England, trusts and primary care colleagues. The IMT was co-chaired by BSol ICB CMO and SMBCs DPH.

Engagement cell – active listening and co design

The engagement cell collected soft intelligence with existing and newly established community and voluntary sector partners. This soft intelligence was collected through community engagement activities and coded for theme, inclusion group, and locality. Using these insights and behavioural change approaches, the IMT were able to understand the public’s views on vaccinations, barriers to access, and causes of vaccine hesitancy. This intelligence resulted in revised designs and bespoke communications for audiences in low uptake communities.

Making vaccinations accessible

Catch up service

Birmingham and Solihull participated in the national catch-up scheme targeted at patients up to 25 years old who had not received the MMR vaccination as a child. This was a cohort known to have been impacted, and continues to be impacted, by hesitancy generated by disproven claims regarding the link between the vaccine and autism. 

Uptake in patients under 25 who had missed the childhood MMR was good under this scheme, but performance for under-fives remains a challenge. 

Vaccinations in schools

IMT identified unvaccinated children as a key source of transmission, and targeted schools for catch-up vaccination clinics in areas where there was low MMR uptake. These catch-up clinics supplemented core GP MMR delivery through the NHS England schools vaccination contract.

Call/recall

The BSol I&V team established a call and recall service. The staff reached out to patients who had previously turned down three offers of MMR vaccinations for their children. The team conducted risk stratification across practices and selected 25 practices eligible for the service. 

The practices provided the call/recall team with contact information and preferred language for parents of patients aged one to 25. SVOC bank staff trained in motivational interviewing contacted patients to discuss the reasons they had opted out of previous offers and alleviate concerns around vaccine safety. Patients received up to three calls, and if they consented to take up the vaccine, were booked in with their local GP practice. The team completed around 100 to 120 calls per person in a seven-hour working day.

The team found that parents valued the opportunity to discuss their concerns beyond a ten-minute appointment and staff were able to debunk myths, including the link between the MMR vaccine and autism. 

Reaching ethnic and faith groups

Community engagement revealed concerns and lower uptake among some ethnic and religious groups in Birmingham and Solihull. 

The team identified barriers including language differences, health literacy, and high levels of misinformation across Roma, Romanian, South Asian and black ethnic groups. Language barriers were addressed by increasing the materials available in a range of languages, including creating new translations to meet the needs of patients who had been unable to find material in their native language. More visual material, including images with more representative families and QR codes that linked to videos in a range of languages, also helped patients to engage with the messages around vaccination benefits. Behavioural research on local communities found that including more diverse families on the posters supported patients to recognise themselves in the campaign and to identify with the need to get vaccinated.

Health literacy and misinformation were addressed through direct conversations with patients. In all groups, following the COVID-19 vaccination programme, and in religious and minority ethnic groups, these concerns were coupled with higher distrust of healthcare settings and government messages. Engagement with community leaders and influencers included ‘myth busting’ the misconceptions about the safety and efficacy of the vaccine. The engagement provided evidence-based information about the disease impact potential of measles and the benefits of the vaccine. In some communities, the word ‘vaccine’ had become charged and so teams switched to ‘immunisations’ which did not carry the same level of negative connotations associated with vaccination misinformation.

Results and benefits

• There was an increase of over 6,000 MMR vaccinations over the course of the measles outbreak, with 21 per cent more MMR vaccinations achieved overall in 2024 than in 2023.
• There was a noticeable positive impact on MMR activity as a result of the communications and marketing campaigns conducted December 2023 and this activity correlated with an increased uptake.
• Learning from the 2023-24 outbreak has been used to design the response to 2025 cases, resulting in a smaller, shorter rise in cases.
• The soft intelligence collected by the engagement cell through community engagement activities enabled the IMT to understand the public’s views on vaccinations, barriers to access, and causes of vaccine hesitancy. This intelligence resulted in revised designs and bespoke communications for audiences in low uptake communities.
• As a direct result of conversations with the call/recall team, 978 patients had MMR vaccinations who otherwise were unlikely to have done so. 

Challenges and key learning

• Materials need to represent the different communities and their populations often at a hyper local level. Information needs to be accessible to a range of languages and tailored to differing needs.
• Visual materials were preferred across a range of populations and written material needed to be suitable for patients with a reading age of nine, as this is the average across the system.
• To ensure ongoing improvements to health literacy, and to build more trust in less engaged communities, MMR should not be considered in isolation but as part of a wider immunisation and general health and wellbeing offer.

Vaccine hesitancy

• Vaccine hesitancy has continued to grow. The Birmingham and Solihull team identified strong concerns regarding the disproven link between autism and vaccinations.
• Members of faith groups who do not consume pork were often concerned by the porcine content of the MMR vaccine and unaware of the porcine-free version. When vaccinators were able to provide an alternative option alongside a discussion of the benefits of vaccination, patients in this category were more likely to take up the vaccine.
• While the catch-up service broke through in the ten-to-25 age group, uptake for the under-fives is still problematic, indicating that sustained commitment to engagement and education is required to reach parents with concerns.

Low demand

• Vaccine hesitancy and health literacy impacted on demand, but the team also identified issues around timing. Attendance declined over Easter and Ramadan, prompting the team to consider timing future campaigns earlier in the year, or pausing appointments over major holidays and periods of religious observance.
• Working with patients to overcome vaccine hesitancy is a high intensity activity. The call/recall service found that nine-to-ten calls yielded one appointment.
• Birmingham and Solihull ICB I&V Team had £482,000 of ICB-approved funds to support the vaccination programmes while also making cost reduction savings of c£500,000
  • The call/recall services also averaged a 56 per cent DNA rate. To improve uptake, the caller team began contacting patients two-to-three days before their appointment to remind them and discuss any lingering concerns.

Funding

• Funding has declined drastically since the height of the COVID -19 vaccination programme.
• The health inequalities funding, which could be used to support outreach to many under engaged patients, has fallen by 70 per cent between 2024/25 and 2025/26.
• Birmingham and Solihull ICB I&V Team had £482,000 of ICB-approved funds to support the vaccination programmes while also making cost reduction savings of c£500,000
  • Vaccination efforts have been proven by UKHSA to provide a £7.20 return for every £1 invested and marks a major target for the shift to prevention.
  • Sustained and recurrent funding will be required in order to overcome the current vulnerabilities to the population’s health protection.
• The measles response lasted between October 2023 and June 2024, which consumed significant resources and commitment at the expense of proactive prevention strategies. However, this did support future learning and application of new approaches to positive effect.