Vaccination has made an enormous contribution to global health. Today, however, the UK, US, and many other countries with successful immunization programs are experiencing concerning outbreaks of disease (particularly measles) as a result of declines in vaccine coverage.3 For example, Public Health England describes the National Health Service (NHS) routine immunization schedule as world-leading; however, reduced engagement with the program means that children may be at an increased risk of vaccine-preventable diseases. In England in 2018–19, coverage declined in all of the routine childhood vaccinations compared with the previous year.4 Additionally, since 2010, routine immunization coverage of the first dose of a measles-containing vaccine (MMR) has declined in 12 European Union member states.5 In 2018, more than 80,000 people in European countries contracted measles, three times the total reported in 2017.6 Globally, there has been a surge in measles due to gaps in vaccination coverage, with an estimated 110,000 deaths related to the disease in 2017, a 30% increase on 2016.7 Recently, the World Health Organization (WHO) stated that, globally, all targets for disease elimination are behind schedule, and lists vaccine hesitancy as one of the top 10 threats to global health in 2019.1 Likewise, the recent 2018 Global Monitoring report from the Wellcome Trust named vaccine hesitancy as one of 10 major threats to global health.8 The 2018 assessment report of the Global Vaccine Action Plan (GVAP) stressed the need to “maintain its hard-won gains but also aim to do more and to do things better, which may involve doing things differently.”9(p.4)
The decline in vaccination uptake is likely to be underpinned by a number of factors including:
- concerns about the vaccines10
- misunderstanding around the severity of the diseases11
- parents who are resentful of perceived pressure to risk their own child's safety for a public health benefit12
- inconvenient or limited access to vaccines13
- mistrust of health professionals, governments, and officially endorsed vaccine research14
- reliance on media and other unofficial information sources15
- increased anxieties about the vaccine's safety as the perceived threat of that disease decreases due to its absence12
- “hard to access” populations (e.g. looked-after children, traveler communities, etc)16,17
- vaccination hesitancy18 (defined as “the reluctance or refusal to vaccinate despite the availability of vaccines”1(p.1))
- opposition to vaccination on religious grounds (e.g. Orthodox Jewish populations)19
- non-religious anti-vaccination (or “anti-vaxx”) sentiment.20,21
Every year, millions of children and young people attend hospital (secondary or tertiary medical care) as outpatients or inpatients.22 Those who attend the pediatric emergency department (PED) for example, often do so with minor illnesses and injuries, which could be better managed elsewhere. Despite numerous initiatives to re-direct these children and young people, PED attendances continue to increase year-on-year.23 In addition to their primary reason for attendance, children in hospital may have lower than average levels of health generally.24 The increased use of hospitals has led to increases in waiting times over the past few years (the median waiting time in the emergency department (ED) in 2017 was two hours and 28 minutes, up from two hours and nine minutes in 2013).25 Whilst many children and young people may have to wait whilst in hospital to see a healthcare professional, little has been done to use this waiting time to improve their health. Hospital settings, where patients have available time, may offer opportunities to deliver novel interventions to improve routine childhood vaccination uptake – this might include: motivational interviewing, referral to vaccination services, or immediate catch-up vaccination, amongst others. The concept of delivering an intervention based, for example, in the ED is not novel. In recent years, several studies have explored the effectiveness of a range of ED-based interventions (alcohol cessation, smoking cessation, improved follow-up care for asthma, mental health). However, the literature is weighted heavily towards interventions for adults. For example, D’Onofrio and Degutis26 performed a systematic review of the medical literature to evaluate screening and brief intervention programs for alcohol-related problems in the ED. The study populations included in the review were diverse, with participants from inpatient and outpatients, and ages ranging from 12 to 70 years. They recommended that these be incorporated into routine clinical practice.
The routine vaccination schedule in the UK is offered in primary/community care, and the majority of interventions to improve vaccination uptake have been implemented in this setting.27 Changes in the way patients engage with healthcare services indicates that alternative settings, such as secondary/tertiary care may also offer appropriate settings for the delivery of interventions such as routine vaccination. However, before we can explore the potential for hospitals to be used as settings for interventions – such as screening, brief intervention and referral to treatment – to increase vaccination, the existing evidence base must first be understood. National Institute for Health and Care Excellence (NICE) guidance recommends that research should explore the most effective ways of modifying services to increase vaccination among children and young people.28 The same NICE guidance highlights gaps in the evidence including “a lack of UK evidence on the effectiveness and cost-effectiveness of different interventions aimed at increasing immunization uptake among children and young people aged under 19 years, particularly among those who may not have been immunized or only partially immunized.”2(p.1) A scoping review will provide evidence towards assessing this issue by identifying novel interventions to improve routine childhood vaccination uptake delivered in secondary and tertiary care settings.
A preliminary search for existing scoping reviews or systematic reviews has been conducted using the JBI Database of Systematic Reviews and Implementation Reports, PROSPERO, and Cochrane Database of Systematic Reviews. No relevant systematic or scoping reviews were found. The objective of this scoping review is to identify and collate the available quantitative literature to identify and describe the interventions that are delivered in secondary and tertiary healthcare settings to improve vaccination uptake in children and young people. This protocol follows the JBI approach to the conduct of scoping reviews29,30 by using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and guidelines.31
What are the interventions delivered in secondary or tertiary medical care settings focused on improving routine vaccination uptake in children and young people?
Participants will include children and young people (aged less than 16 years) and/or their parents/carers (potentially interventions could be delivered to the child-parent/carer dyad) present in a secondary or tertiary care setting as either an inpatient, outpatient, or visitor. In the UK, an individual is legally a child until their 18th birthday;32 however, in clinical practice, most young people will transition from pediatric services to adult services around the time of their 16th birthday.
This review will consider studies that explore interventions to improve routine vaccination uptake delivered in secondary or tertiary care settings. These interventions may include: motivational interviewing, referral to vaccination services, educational intervention or an immediate catch-up vaccination.
The scoping review will include studies based in secondary and tertiary healthcare settings within any country.
Types of sources
This scoping review will consider quantitative study designs for inclusion. In addition, quantitative systematic reviews and meta-analyses will be considered for inclusion in the proposed scoping review. Articles published in English will be included. Articles published from 1989 to the present will be included. This cut-off coincides with significant changes to the NHS routine vaccination schedule (the inclusion of the MMR vaccine).
The proposed scoping review will be conducted in accordance with the JBI methodology.30
The search strategy will aim to locate both published and unpublished primary studies, reviews, and opinion papers. An initial limited search of MEDLINE was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of articles selected for full text review will be screened for additional papers.
Articles published since 1989 in English and indexed in MEDLINE, CINAHL, Cochrane Library, Embase, and Web of Science will be searched. Gray literature will be included through searches of The Healthcare Management Information Consortium (HMIC) Database (containing the UK Department of Health Library and King's Fund Library), and OpenSIGLE.
Articles identified by the search, and considered to meet the inclusion criteria, will be collated and uploaded into EndNote X9.0 (Clarivate Analytics, PA, USA). Duplicates will be removed. Two reviewers will independently select articles matching the inclusion criteria, firstly based on their title, and then abstract. Articles identified through reference list searches will also be considered for inclusion based on their title. Discrepancies in reviewer selections will be resolved through discussion between reviewers prior to full-text retrieval of selected articles. Reasons for excluding full text studies will be documented and reported in the review. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-ScR) flow diagram.31
Data will be extracted from papers included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers. Data will be extracted using a draft data extraction tool based on JBI recommendations (Appendix II). The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. Two reviewers will independently read all articles retrieved through the search strategy; any that do not fit with the aims of the scoping review will be discussed and, if necessary, removed. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Study findings will be presented in tabular form detailing the interventions identified in the literature and the corresponding outcomes. If appropriate, a diagrammatic chart will be used to describe themes derived from the literature. Data will be presented alongside a narrative summary of the findings. Expert methodological advice and input will be sought if necessary.
Appendix I: Search strategy
MEDLINE. Search date: September 2019
Appendix II: Data extraction instrument
1. World Health Organization. Ten threats to global health in 2019 [Internet]. 2019 [cited 13 Aug 2019]. p. 1. Available from: https://www.who.int/emergencies/ten-threats-to-global-health-in-2019
2. NICE. Appendix D: Gaps in the evidence. Immunisations: reducing differences in uptake in under 19 s [Internet]. 2017 [cited 1 May 2019]. p. 1. Available from: https://www.nice.org.uk/guidance/ph21/chapter/Appendix-D-Gaps-in-the-evidence
3. Paules CI, Marston HD, Fauci AS. Measles in 2019 – going backward. N Engl J Med
2019; 380 (23):2185–2187.
4. NHS Digital. Childhood vaccination
coverage statistics - England 2018-19 [Internet]. 2019 [cited 6 Oct 2019]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-immunisation-statistics/england-2018-19
5. Larson HJ, Figueiredo A de, Karafillakis E, Rawal M. The state of vaccine confidence in the EU: 2018: The Vaccine Confidence Project [Internet]. 2018 [cited 6 Oct 2019]. Available from: https://www.vaccineconfidence.org/research/the-state-of-vaccine-confidence-in-the-eu-2018/
6. Thornton J. Measles cases in Europe tripled from 2017 to 2018. BMJ
7. World Health Organization. Measles cases spike globally due to gaps in vaccination
coverage [Internet]. 2018 [cited 27 Mar 2019]. Available from: https://www.who.int/news-room/detail/29-11-2018-measles-cases-spike-globally-due-to-gaps-in-vaccination-coverage
8. Wellcome Trust. Wellcome global monitor 2018 [Internet]. 2018 [cited 19 Jun 2019]. Available from: https://wellcome.ac.uk/reports/wellcome-global-monitor/2018
9. World Health Organization. Strategic Advisory Group of Experts on Immunization. 2018 Assessment report of the global vaccine action plan [Internet]. 2018 [cited 2 Oct 2019]. p. 4. Available from: https://www.who.int/immunization/global_vaccine_action_plan/SAGE_GVAP_Assessment_Report_2018_EN.pdf?ua=1
10. Smailbegovic MS, Laing GJ, Bedford H. Why do parents decide against immunization? The effect of health beliefs and health professionals. Child Care Health Dev
2003; 29 (4):303–311.
11. Hilton S, Hunt K, Petticrew M. Gaps in parental understandings and experiences of vaccine-preventable diseases: a qualitative study. Child Care Health Dev
2007; 33 (2):170–179.
12. Brown KF, Kroll JS, Hudson MJ, Ramsay M, Green J, Long SJ, et al. Factors underlying parental decisions about combination childhood vaccinations including MMR: A systematic review. Vaccine
2010; 28 (26):4235–4248.
13. Thomson A, Robinson K, Vallée-Tourangeau G. The 5As: a practical taxonomy for the determinants of vaccine uptake. Vaccine
2016; 34 (8):1018–1024.
14. Casiday R, Cresswell T, Wilson D, Panter-Brick C. A survey of UK parental attitudes to the MMR vaccine and trust in medical authority. Vaccine
2006; 24 (2):177–184.
15. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine hesitancy. Hum Vaccines Immunother
2013; 9 (8):1763–1773.
16. Jackson C, Bedford H, Cheater FM, Condon L, Emslie C, Ireland L, et al. Needles, jabs and jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among gypsies, travellers and Roma. BMC Public Health
2017; 17 (1):254.
17. Walton S, Bedford H. Immunization of looked-after children and young people: a review of the literature. Child Care Health Dev
2017; 43 (4):463–480.
18. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine
2015; 33 (34):4161–4164.
19. Letley L, Rew V, Ahmed R, Habersaat KB, Paterson P, Chantler T, et al. Tailoring immunisation programmes: using behavioural insights to identify barriers and enablers to childhood immunisations in a Jewish community in London, UK. Vaccine
2018; 36 (31):4687–4692.
20. Rossen I, Hurlstone MJ, Dunlop PD, Lawrence C. Accepters, fence sitters, or rejecters: Moral profiles of vaccination
attitudes. Soc Sci Med
21. Jolley D, Douglas KM. The effects of anti-vaccine conspiracy theories on vaccination
intentions. PLoS One
2014; 9 (2):e89177.
24. Johnson L, Cornish R, Boyd A, Macleod J. Socio-demographic patterns in hospital admissions and accident and emergency attendances among young people using linkage to NHS hospital episode statistics: results from the Avon Longitudinal Study of Parents and Children. BMC Health Serv Res
2019; 19 (1):134.
25. The King's Fund. What's going on with A&E waiting times? [Internet]. [cited 5 Jun 2019]. Available from: https://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters
26. D’Onofrio G, Degutis LC. Preventive care in the emergency department: Screening and brief intervention
for alcohol problems in the emergency department: a systematic review. Acad Emerg Med
2002; 9 (6):627–638.
27. Crocker-Buque T, Edelstein M, Mounier-Jack S. Interventions to reduce inequalities in vaccine uptake in children and adolescents aged <19 years: a systematic review. J Epidemiol Community Health
2017; 71 (1):87–97.
28. NICE. 5 Recommendations for research. Immunisations: reducing differences in uptake in under 19 s [Internet]. 2017 [cited 1 May 2019]. Available from: https://www.nice.org.uk/guidance/ph21/chapter/recommendations-for-research
29. Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc
2015; 13 (3):141–146.
30. Peters MDJ, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Chapter 11: Scoping Reviews. In: Aromataris E, Munn Z (Editors). JBI Reviewer's Manual [Internet]. 2017 [cited 18 Dec 2019]. Adelaide: JBI. Available from: https://reviewersmanual.joannabriggs.org/
31. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med
2018; 169 (7):467.
32. UNICEF. What is the convention on the rights of the child? [Internet]. [cited 14 Aug 2019]. Available from: https://www.unicef.org/child-rights-convention/what-is-the-convention