Research and analysis

Appendix 4. Narrative review of the determinants of vaccination uptake

Published 5 March 2026

Applies to England

Access

Definition: ‘the ability of individuals to be reached by, or to reach, recommended vaccines’.

Appointment availability and flexibility

In several small studies with people with underlying medical conditions, the availability, flexibility and ease of booking appointments facilitated vaccination, with some citing examples of convenient GP clinic arrangements (for example, evening and weekend appointment slots) or the option to attend a private pharmacy in the absence of GP appointments (1, 2, 3). However, there were contrasting views among pregnant women, some finding booking antenatal vaccination appointments easy and efficient, albeit with suggestions for greater availability outside of working hours, while others reported confusion and delays associated with online self-referral forms (4, 5). A survey of approximately 1,500 women who were pregnant during the pandemic found that over a third reported that their GP appointment for a pertussis vaccine was changed, postponed or cancelled during the pandemic (6).

Parents of young children also cited difficulties in making appointments due to limited availability and flexibility, appointment changes or errors, and faulty online registration and telephone booking systems, with the resultant dissatisfaction undermining trust in the wider system (7). One study involving Bangladeshi parents found that the ease of booking vaccination appointments was a facilitator among this ethnic minority community that exhibits high childhood vaccination uptake (8). Other appointment barriers included difficulties navigating the UK primary healthcare system and uncertainties around entitlement to care among Polish and Romanian community members and Gypsy, Roma and Traveller (GRT) populations, while interviews with primary care professionals highlighted how adult migrants are often excluded from catch-up vaccination initiatives, contrasting with the incentivisation to offer appointments to migrants under the age of 5 years (9, 10, 11). The COVID-19 pandemic presented additional barriers for parents of young children who variously cited difficulties in registering with a GP and organising vaccination appointments, reduced opportunities for face-to-face appointments, and fears around contracting COVID-19 while attending the practice (12, 13).

The availability of appointments and travel distances were cited as accessibility barriers by young adults, whereas in a sample of mostly people identifying with an ethnic minority, receiving the vaccine in a well-trusted access point (for example, food banks, community centres and charities) was viewed as a facilitator of COVID-19 vaccination (14, 15, 16). Evidence that alternative locations facilitate higher uptake was found in a range of populations, including a doubling of the odds of uptake of the seasonal influenza vaccine in schools-based programmes compared to a GP-delivery model, delivering vaccinations in hotels and other accommodation sites housing people seeking asylum and refugees, and providing adults with chronic respiratory conditions a variety of vaccination opportunities, such as during routine check-ups and at mass vaccination events (17, 18, 19).

A study in a more deprived, ethnically diverse, low uptake area of London revealed a range of opinions regarding vaccination sites, some preferring to attend a known location with a trusted healthcare professional (for example, their own GP), while others wanted vaccines to be delivered in alternative locations such as community pharmacies (7). Integrating vaccinations into routine antenatal care appointments was a key facilitator of uptake among pregnant women, while a higher perception of inconvenience was found among those who were unvaccinated (4, 20, 21, 22).

Among healthcare workers, a lack of convenient access to vaccination sites was cited by medical students, whereas perceived accessibility was not associated with vaccination status among pharmacy staff, indicating that individuals may be actively choosing not to be vaccinated (23). A total of 170 Interviews conducted in 2019 with over 50 influenza vaccination programme managers and vaccinators revealed that Trusts with a high uptake among HCWs endeavoured to reach most remote satellite sites, prioritised high-risk areas, and maximised convenience by taking the vaccine to staff rather than asking staff to go to vaccination services (24).

However, interviews with service providers, vaccination commissioners and programme managers, revealed that delivering vaccinations in non-primary care settings was viewed as having limited logistical and resource feasibility. A total of 156 Interviews with stakeholders working in COVID-19 vaccination delivery across 4 regions of England suggested that primary care-led models, and to some extent pharmacies, were perceived to offer a better combination of efficiency and community reach for equitable delivery (25).

Language and communication barriers

Among migrants and ethnic minorities, language and communication barriers were highlighted in a number of studies from both a service user perspective (for example, a lack of officially translated leaflets, lack of access to an interpreter) and from service providers who cited that using interpreting services and translating vaccination histories provided in languages other than English was time-consuming and difficult to organise (7, 9, 5, 26 10 27, 28, 29, 30). Several further studies cited culturally and linguistically accessible and tailored information as either a barrier, when lacking, or a potential facilitator to vaccination among migrants and ethnic minorities (16, 29, 30, 32). For example, among Congolese adult migrants, suggestions included creative forms of expression such as music, theatre, art, and dance (30). Analysis of minority-boosted longitudinal data from 40,000 households reported systematically lower access to all forms of healthcare among Black and Mixed Caribbean individuals as a potential mechanism underlying inequalities in vaccination uptake (33). The authors hypothesise that lower COVID-19 vaccine confidence among these groups may be “a form of retaliatory or other behaviour resulting from limited access to healthcare” (33).

A lack of digital literacy and difficulty navigating the online booking system were cited as access barriers in studies of various methodologies, including sentiment analysis of social media data, in-depth interviews with members of the Nepali community, and semi-structured interviews with primary care professionals and recently-arrived migrants (28, 29, 34).

Logistical factors

Vaccine shortages were reported among a range of populations and vaccination programmes including immunosuppressed adults and parents of young children seeking influenza vaccination, GBMSM trying to obtain the mpox vaccination, and GP practices attempting to perform catch-up vaccinations with adult migrants, the latter due to difficulties in anticipating demand (35, 1, 36, 37). The underlying reasons for these reported shortages were not described in depth and warrant further investigation.

A number of studies highlighted the challenge of accessing vaccinations whilst caring for babies or multiple children (12, 11). In the context of the 2022 London polio booster campaign, establishing a complementary delivery pathway embedded in a community setting was viewed as more family friendly by the Orthodox Jewish community when attending with multiple children.195 Large families faced particular challenges during the COVID-19 pandemic due to the restrictions on the number of parents and children able to attend the practice at any one time (12).

The pandemic presented a further range of access barriers including disruption to antenatal care appointments, concerns over the safety of receiving vaccinations in proximity to others among immunosuppressed adults, and a lack of clarity around whether routine vaccination services were operating as usual (6, 1, 12). These issues were exacerbated among ethnic minorities and lower income households (6, 12). The demands of attending higher priority medical appointments was a specific barrier cited by immunosuppressed adults (1).

Affordability

Definition: ‘the ability of individuals to afford vaccination, both in terms of financial and non-financial costs (for example, time)’.

Whilst socio-economic status was consistently shown to be highly correlated with vaccination uptake in the UK, specific issues regarding affordability were not prominently reported as key barriers to vaccination within the qualitative literature. The offer of vaccinations via the NHS, with no cost at the point of care, was specifically cited as a facilitator among Bangladeshi parents, who compared this to the health system in Bangladesh where vaccinations are not always free nor accessible (8). In contrast, the lack of certainty over entitlement to care and the perception of potential financial costs were identified as barriers by various adult migrant populations (26). Numerous studies cited indirect financial costs through the necessity to take time off work to attend vaccination appointments where there was limited flexibility in appointment times (2, 7 20 36). This was a particular issue for GBMSM seeking an mpox vaccination who work in insecure or low income professions (37). Reference to non-financial costs and barriers were also rare but centred on competing demands on participants time, for example wider family commitments among pregnant and Roma Romanian women (20, 26).

Awareness

Definition: ‘the degree to which individuals have knowledge of the need for, and availability of, recommended vaccines and their objective benefits and risks’ (38).

Awareness of eligibility

Awareness of one’s eligibility for vaccinations was identified as an important factor in the uptake of influenza and/or pneumococcal vaccination among at-risk and older adults (39, 1, 2). In one study, a greater awareness of eligibility for the influenza vaccine, when compared to pneumococcal and shingles vaccines, correlated with higher self-reported uptake (39). In another, by far the strongest predictor of influenza vaccine uptake was previous receipt of the vaccination (40). Among over 8,500 GBMSM surveyed during the evaluation of a pilot HPV vaccination programme, there was low overall awareness of the recommendation to receive the vaccine among this population, even lower among those attending clinics in ‘rural village and dispersed’ settings (41). Smaller surveys with GBMSM found a lack of awareness as the most common reason for not completing a full course of HPV, hepatitis A, and/or hepatitis B vaccination, and those who had heard about HPV vaccination from at least one source were 15 times more likely to have initiated the vaccination series than those who had not heard about it from any sources (42, 43). A general misunderstanding regarding vaccinations and the immunisation schedule (for example, “one shot cures all diseases”) was as a barrier to uptake among Roma Romanian community members (26).

Sources of information

For parents and pregnant women, sources of vaccine information included healthcare professionals, family and friends, online forums and other sources such as the BBC, NHS and government websites (4, 36, 44, 45) There were strong preferences for face-to-face conversations and opportunities to discuss concerns with trusted healthcare professionals in this population group, with one study suggesting that the advice of midwives was valued more highly than advice from other HCWs (7, 22, 44). However, some parents perceived public health and NHS information as unclear or biased and turned to alternative sources (46, 47).

Having the need for vaccination adequately explained by a healthcare professional was a facilitator among various adult migrant populations, although some were more influenced by family and friends or community members, particularly when they were hesitant or undecided about vaccination (27). Interviews with Polish and Romanian community members found that, despite most trusting NHS literature on vaccinations, some struggled to find trustworthy sources amidst the volume of online information, such as parent forums and social media (10). In a study of 44 members of the GBMSM community, most participants reported obtaining mpox information through social media platforms or peer-to-peer communication, including information about vaccination sites; these sources were considered relatable and helpful when coming from key organisations and voices from within the LGBTQ+ community (37).

With regard to the COVID-19 vaccination, younger adults’ preference for social media and messenger services was associated with a lower probability of vaccination in one study (48). Similarly, a survey of a nationally representative sample of over 2,000 adults found that those resistant to vaccination had lower trust in traditional or authoritative sources of information (49). Furthermore, a community survey of over 1,000 residents belonging to ethnic minorities in a large town in the East of England found that obtaining information from objective sources was protective against hesitancy (50). The opportunity to discuss concerns with healthcare professionals or other trusted sources, involving healthcare workers in vaccine promotion, and promoting vaccination through trusted networks were all facilitators of COVID-19 vaccination uptake (30, 51, 52). In one specific population group, immunosuppressed adults with IMIDs, having a healthcare professional’s confirmation of vaccine suitability for their IMID was a key facilitator, as was the visible impact of the vaccination programme via the intense media focus on the pandemic response (1).

Sufficiency of information

In various studies, participants revealed a demand for information tailored to their specific needs (that is, pregnancy) and delivered through personal engagement rather than relying on written materials (5, 7, 45, 46, 53). Indeed, fewer opportunities to ask questions about routine childhood vaccinations due to the restrictions of the COVID-19 pandemic was identified as a barrier in one study (13). However, in a separate study, middle-class women who were UK citizens felt well-informed (and sometimes overwhelmed with information) regarding their vaccination decisions, while more marginalised women, especially those whose first language was not English, found it difficult to understand verbal information (44). Focus groups with staff members of school-aged vaccination teams found that insufficient education about the HPV vaccine resulted in an under-appreciation of its importance and negative parental attitudes, including the perception that the vaccination promotes promiscuity, particularly in areas of deprivation and/or ethnic diversity where language barriers may exist (54). Various methods of overcoming this barrier were reported, such as hosting school open evenings, providing direct information over the phone, and the provision of culturally sensitive and language appropriate materials (54). A study involving patients with chronic respiratory conditions found that a lack of detailed and tailored information about how and why vaccination works led to feelings of being unable to make an informed decision and hindered trust in vaccinations (13).

Intention to receive the COVID-19 vaccination was significantly associated with greater perceived information sufficiency to make an informed decision and knowledge of symptoms and transmission was protective against hesitancy (50, 55, 56). However, in one study involving interviews with Congolese adult migrants, the amount of official public health information was ‘overwhelming’ and acted as a barrier (30). Several studies found that ‘inconsistent’, ‘contradictory’ and ‘conflicting’ public messaging and media information led to mistrust and low confidence in health authorities and the government, thereby acting as a barrier to uptake (20, 31, 52, 57). In one study of parents views on the COVID-19 vaccination, the willingness to vaccinate offspring decreased with younger age, which the authors hypothesised as a response to a relatively scant evidence base and therefore less clear media reporting of the risks and benefits in the very young (58).

Misinformation

Misinformation was a source of low vaccine confidence among a diverse range of population groups; pregnant women, Polish and Romanian community members, and Bangladeshi parents all cited the false association between the MMR vaccine and autism or other ‘developmental problems (4, 7, 8, 10). In the latter, low confidence in the MMR vaccine was found to be higher among second and third-generation Bangladeshi parents, perhaps due to increased agency in health decisions and higher exposure to online material (8). Other false beliefs were reported among Roma Romanian women including that vaccines can cause impotence, contain human tissue, and are part of a religious conspiracy (26). Social media was perceived by some GBMSM to relay personal and subjective, often extreme, mpox experiences with the possibility of promoting misinformation (37). However, analysis of national vaccine coverage data, survey responses and social media posts suggests that anti-vaccination sentiment is unlikely to have been a major contributor to the decline in vaccine coverage for some vaccines in England since 2012/13, with evidence suggesting that the decline was in fact preceded by an increase in vaccine confidence and a decrease in the proportion of parents encountering anti-vaccination material (59). Barriers relating to language, digital exclusion and limited social networks all limited exposure to official health promotion information, presenting opportunities for online misinformation and conspiracy theories to influence decision-making (5). These were particular concerns for pregnant women, GBMSM, and people seeking asylum and refugees whose first language was not English (5, 18, 37).

Misinformation regarding COVID-19 vaccines was frequently cited within the literature as a source of uncertainty or hesitancy. This was particularly common among studies conducted with migrants and ethnic minorities which, coupled with pre-existing distrust of vaccinations and the NHS, was deemed likely to negatively affect vaccination uptake (28, 29, 31, 51, 57, 60). Even among healthcare workers from 2 large London-based hospital trusts, the spread of misinformation online influenced attitudes towards COVID-19 vaccination, particularly among junior level staff and those belonging to ethnic minorities (61). Studies with representative samples of the general UK population also found misinformation, and particularly conspiracy suspicions, to be powerful predictors of vaccine hesitancy (62, 63, 64, 65). In one survey of nearly 1,500 adults in the UK, those who obtain information from relatively unregulated social media sources, that have recommendations tailored by watch history, and who hold general conspiratorial beliefs, were less willing to be vaccinated (63).

Suggestions to overcome misinformation barriers included tailoring information to address clients’ specific needs, creating sufficient time and space to discuss concerns, directing those exposed to misinformation to trusted sources, and providing hardcopy information (5, 18).

Perception of risk

For adults with underlying medical conditions, a greater perception of risk and severity of infection served to promote uptake of selective vaccinations and motivated parents of pre-school children and pregnant women towards influenza vaccination uptake (1, 2, 21, 36). Previous personal experience of vaccine preventable diseases, or witnessing others’ illnesses, was also a facilitator (2, 20). Conversely, a low perception of risk was identified as barrier to uptake across various population groups including parents and guardians of young children, adults with underlying medical conditions, GBMSM, and ethnic minorities (3, 10, 12, 19, 36, 43, 47, 66, 67, 68). Specific barriers included a lack of tailored information about the relevance of influenza vaccination for adults with underlying (particularly non-respiratory) conditions, and beliefs that influenza infection is ‘inevitable’ in children or that vaccine preventable diseases are ‘historic’ childhood illnesses (3, 36, 47).

A greater perception of risk from COVID-19 infection was also found to be a facilitator of vaccination uptake in a number of population groups (1,44, 55, 69, 70, 71, 72, 73). For example, among higher risk adults (older adults aged over 65 and younger adults with chronic respiratory disease), perceptions of personal susceptibility, severity and contagiousness of the disease, and the health consequences of others were identified as key facilitators to vaccination intention (70). The impact of COVID-19 was also found to substantially increase the likelihood of uptake of both the influenza and pneumococcal vaccinations among eligible participants (70). Similarly, the protection of others, such as family, friends and other high risk members of society, was also a motivating influence (14, 15, 28, 57, 74). For example, a desire to protect at-risk individuals was a key facilitator of uptake among care home employees in the North West (72).

Beliefs regarding vaccine efficacy

Beliefs that nutritional and home remedies are effective in preventing infection, a reliance on ‘natural immunity’ as sufficient protection, scepticism over the need for multiple or booster doses of vaccination, and the belief that only older or at-risk adults need to be vaccinated were all beliefs associated with uncertainty or unwillingness to receive the COVID-19 vaccination (16, 28, 30, 34, 57, 71, 74, 75, 76). Concerns over the efficacy of the COVID-19 vaccines among young adults were exacerbated by a lack of trust in government and the misunderstanding of the science of vaccination, although most participants in this study did not consider themselves to be ‘anti-vaccine’ (74). Doubts regarding vaccine efficacy in general and a preference for ‘natural immunity’ were also commonly reported for a range of other vaccinations, including by pregnant women, mothers, migrant populations, at-risk adults, and healthcare workers and medical students (1, 4, 20, 23, 26, 27, 39, 47, 53, 66, 68, 77).

Acceptance

Definition: ‘the degree to which individuals accept, question or refuse vaccination’.

Vaccine safety

For some, concerns regarding side effects and adverse outcomes were based on personal experience and included adverse reactions or ‘immune responses’ among adults managing long-term conditions and adolescent girls declining the second dose of HPV vaccine (3, 7, 19, 47, 54). For others, concerns were more hypothetical and based on beliefs around unforeseen future effects and potential vaccine-related harms, particularly with regard to the seasonal influenza vaccine (1, 10, 39, 78). In a survey of over 2,500 randomly selected adults across Britain, a higher perception of risk of side effects was associated with increasing deprivation, current unemployment, lower level of education, higher internet use, and with Asian and Black ethnicities (68). In contrast, 2 studies reported that previous positive experiences of receiving vaccinations, either personally or in a close family member, served as facilitators (1, 4). Among immunosuppressed adults with immune-mediated inflammatory diseases, the stability of their condition alongside confidence in the safety of vaccines were influences on the acceptance of the influenza and/or pneumococcal vaccinations (1).

A wide range of population groups cited safety concerns with the COVID-19 vaccine including young adults, older and higher risk adults, parents and pregnant women, migrants and ethnic minorities, health care workers, care home employees, and social media users (1, 14, 16, 20, 28, 30, 31, 34, 50, 51, 57, 58, 60, 61, 70, 72, 73, 74, 76, 79, 80, 81). Most centred on the potential for future unforeseen side effects, the perceived novelty of the vaccine, and speed of its development, and a lack of available safety data from long term trials (14, 16, 28, 31, 34, 50, 51, 52, 55, 57, 58, 63, 69, 71, 75, 79, 81, 82). The changing timelines and number of doses were further factors associated with safety concerns (28, 57, 74). Perceived safety was also a concern for pregnant women when considering participation in COVID-19 vaccine trials, introducing an negative feedback loop between safety concerns and strengthening the evidence base (84). Trust and confidence in the vaccination programme interacted with safety concerns in some studies, with young adults’ lack of trust in government exacerbating these concerns, while some among a small ethnically diverse sample of interviewees felt reassured by the medical establishment’s vaccine testing processes (31. 74). Interviews with 24 healthcare workers from 2 large London-based hospital trusts found that uncertainty around the long-term safety of vaccines and a perception that government decisions on vaccine rollout had not been evidence-based impacted their level of trust and confidence in the programme (61).

Issues with vaccine safety more generally were also common among pregnant women and parents, some raising specific concerns of miscarriage and fertility problems or citing harms related to other medical products, for example, thalidomide and its association with birth defects (5, 27, 46, 47). Perceiving vaccines as safe and effective was associated with the length of time that the vaccines have been available, while safety fears and a general wariness of new vaccinations were amplified by the seemingly conflicting advice to avoid most medications during pregnancy (20, 36). In a study undertaken in a low uptake area of London, people from ethnic minorities were more likely to question routine vaccine safety following the COVID-19 pandemic (13).

Other safety concerns included a sense of ‘over-vaccination’ or ‘vaccine fatigue’ for some adult migrant populations, while in one study, some parents reported choosing to space out or delay vaccinations due to the perception that too many vaccines were being given at the same time (35, 7, 27). A fear of needles was referenced in studies with adolescent girls, adults with chronic respiratory conditions, and pregnant women, indicating that this is not a trivial issue for a range of population groups (2, 20, 54).

Trust

Trust, both in vaccinations specifically and in health authorities more generally, was a key influence on uptake in a number of population groups. Among Roma Romanian women, past negative experiences of health care, in Romania and the UK, were cited as causes of distrust among the community (26). Healthcare providers working with GRT populations identified a lack of staff understanding of Travellers’ cultural norms, low English literacy amongst communities with predominantly oral traditions, limited spoken English among Roma communities, and a lack of appropriate interpreter services, as well as isolated instances of discrimination and stereotyping (11). Suggested solutions included ensuring continuity of services, face-to-face engagement, bilingual health workers, and specialist health visitors and community link workers for Traveller communities (11). Healthcare providers working with Polish and Romanian communities reported that some community members were sceptical about the quality of primary healthcare in England and found that engagement was more effective at building trust when using outreach strategies, such as door-knocking and approaching community groups, rather than trying to encourage health service attendance (10).

Interviews with 10 mothers from various socio-economic, educational and cultural backgrounds, all of whom had rejected some or all of their child’s routine vaccinations, found that the dimension of trust was complex, with mothers often looking to experts and credible sources whilst not wholly trusting official government or medical bodies (47). However, few participants identified as an ‘anti-vaxxer’, which was viewed as a derogatory term, and some remained open to new information and future vaccine acceptance depending on the context and individual needs of their child (43). Trust in the NHS, the wider public health system, and in healthcare professionals’ advice was also identified as a facilitator for pregnant women (46, 53). Questionnaire responses from over 300 pregnant women revealed that most (88%) had little or no awareness of RSV, yet most (75%) would likely accept RSV vaccination if routinely recommended (84). White-British women were more than twice as likely to accept routine RSV vaccination than non-White British women (84). In a separate study, White British respondents were more than 3 times as likely to accept influenza vaccination and more than 4 times as likely to accept pertussis vaccination than those identifying with all other ethnic groups (78). Among adults with chronic respiratory conditions, those that had been vaccinated reported feeling that their health needs were being catered for, that their vaccination was administered by a nurse with whom they were familiar and showed concern for them by prompting vaccination during routine visits (19).

Mistrust was a key barrier to COVID-19 vaccination, especially among migrants and ethnic minorities; the focus of this mistrust was variable but included the government, policymakers, employers, healthcare providers, pharmaceutical companies, and vaccines in general (15, 16, 28, 33, 50, 51, 52, 63, 69, 75, 86)). For example, ethnic minorities were less likely to trust scientific or clinical sources than White British participants, whereas Asian/Asian British and Black/Black British participants were more likely to trust faith or community leaders. Similarly, qualitative data from the Born in Bradford research programme identified that White British respondents were more likely to trust the NHS, which was linked to more positive vaccination intention, but distrust the government and local councils, whereas Pakistani respondents were more likely to trust religious settings (60). Furthermore, longitudinal data from the Understanding Society COVID-19 Study shows a complex interaction between trust and ethnicity; while many participants belonging to ethnic minorities tended to mistrust the government, among all participants for whom trust was not an issue, many ethnic minority populations had more positive views towards vaccination uptake (87). Lastly, the lower uptake observed in ethnic minority populations in one survey was associated with lower trust in medics, scientists and government, mediated by worse experiences of NHS healthcare (88). However, this mediating effect accounted for only around a quarter of the variation in uptake by ethnicity, suggesting that factors other than mistrust and poor healthcare experiences have important roles in the lower rates of vaccination observed in ethnic minorities (88).

In other population groups, a UK-wide representative survey of over 4,000 adults found that trust in the NHS, followed by trust in scientists, were the strongest predictors of vaccination intention (48). The level of trust in the UK government was higher in older adults (48). In a survey of over 5,000 adults, ‘excessive mistrust’ was identified as a higher order factor associated with COVID-19 vaccination decision-making, characterised by conspiracy beliefs, negative perceptions of doctors and vaccine developers, negative healthcare experiences, and anger directed at societal structures (62). In contrast, ‘positive healthcare experiences’ with GPs and the NHS, and positive views of doctors and medicine more generally, were associated with greater enthusiasm about a COVID-19 vaccine (62). Trust in the wider vaccination and health system was also a common influence, both positive and negative, on acceptance in an online survey of over 1,000 pregnant women (79). Among participants of a national survey, those with a higher level of educational achievement were more likely to trust healthcare professionals and scientists but less likely to trust pharmaceutical companies (85). Scepticism regarding the commercial interests of pharmaceutical companies was also a common factor in vaccination acceptance among ethnic minorities, parents and older adults (7, 13, 39, 47, 51, 57).

Discrimination

Discrimination, as a higher order factor associated with mistrust, was prominently reported in the qualitative literature exploring COVID-19 vaccination uptake. A qualitative study with 22 Black participants from the UK found that historical factors, such as the abuse of Black bodies within medicine, were possible barriers to COVID-19 vaccination (32). A study of 633 adults from ethnic minority groups demonstrated that 1 in 15 who had refused a COVID-19 vaccination had experienced ethnic or racial discrimination in a medical setting since the start of the pandemic, and twice the number of discriminatory incidents than those who had received the vaccination (89). In a sample of Congolese adult migrants, historical and present-day racism involving the exploitation of Black and African populations by White Europeans, and the perception that the NHS and government were using them as ‘guinea pigs’, were among the key influences on vaccine uptake (30). This latter concern was shared by recently arrived migrants, who also reported the unequal approaches to research and under-representation of ethnic minorities in clinical trials as sources of distrust in the vaccination programme (29). Acknowledgment of health inequalities by health authorities, avoiding blaming ethnic minorities for their ‘lack of compliance’, and community engagement, such as the integration of cultural groups in the planning of health programmes, were potential facilitators of vaccination uptake (13).

Interviews and focus groups with various health system stakeholders and community residents and leaders in Greater Manchester identified that past experiences of discrimination and racism served to reproduce fear, suspicion and mistrust among some ethnic minorities towards the COVID-19 vaccination programme (76). The authors summarise that, for some, the choice not to receive the vaccine had become a ‘metaphor for political dissent against institutional failures for under-served communities who experience marginalisation’ (76). A further 25 semi-structured interviews with UK-based healthcare staff revealed that risk-benefit considerations regarding the COVID-19 vaccination were weighted more heavily towards vaccine hesitancy among staff belonging to ethnic minorities due to perceptions about institutional and structural discrimination (90). This included suspicions around institutional pressure to be vaccinated, racial injustices in vaccine development and testing, and the legitimacy and accessibility of messaging and communication, all reflecting a greater mistrust in institutions involved in vaccine promotion (90).

In-depth semi-structured interviews with 32 recently arrived migrants, including refugees, people seeking asylum, undocumented migrants, and migrants with limited leave to remain, there were concerns that their communities would be excluded or de-prioritised during the roll-out (16). Undocumented migrants described specific fears over being charged or facing immigration checks if they presented for a vaccination (16). There were similar findings in the literature exploring uptake of other vaccination programmes. Interviewees from various adult migrant populations were distrustful towards healthcare professionals and health systems, in part due to experiences of insensitivity from a HCW and fear around data sharing with immigration authorities, when considering catch-up of missed routine vaccinations (27). On the contrary, a high level of trust in the safety and importance of the childhood immunisation programme was observed across generations of Bangladeshi parents, and even ‘blind compliance’ in first-generation Bangladeshi parents with lower health literacy and agency (8).

Some pregnant women linked mistrust of antenatal vaccines to human rights abuses of minority groups involved in clinical trials; one participant lost trust after feeling discriminated against by her initial midwife (5). Similarly, interviews with pregnant women and healthcare professionals in North-East London found a sense of distrust of the government’s perceived involvement in vaccinations among Black Caribbean participants, possibly as a result of intersecting characteristics of socio-economic position, ethnicity and gender, alongside worries that vaccines can affect various populations differently (44). Young, single and/or unemployed women reported feeling judged or that their concerns were dismissed (44). In both of these studies, a lack of continuity of care, particularly for at-risk women, caused difficulties in building relationships with midwives, presenting a barrier to trusting their vaccination advice (5, 44).

Stigma

Stigma was a particular concern for vaccinations against infections associated with sexual transmission. Both adult migrants and parents of adolescent girls exhibited hesitancy around the HPV vaccine, with service providers reporting that the most common barrier among the latter was a concern of indirectly condoning sexual promiscuity (35, 91). Regarding the mpox vaccine, interviews with GBMSM revealed that public health measures were considered highly acceptable and aligned with established sexual healthcare routines but stigma, particularly among ethnic minorities or those from areas with small GBMSM scenes, was a barrier to engagement with these measures due to the perceived risk of disclosure of sexual orientation (37). Some felt that tailored messaging specifying that sexually active GBMSM were primarily at risk of, and responsible for, mpox could reinforce homophobic tropes and stereotypes of promiscuity and recklessness (37).

Cultural acceptability

Cultural differences were also perceived as a potential acceptance barrier in select population groups. Some service providers perceived Traveller culture to be more responsive, rather than proactive, to health needs and thus vaccination is deprioritised (11). Similarly, providers perceived a preference for later and therefore more urgent care-seeking behaviour among Roma Romanian women (26). Among Polish and Romanian community members, a lack of familiarity of the English primary healthcare system and immunisation schedule led to unmet expectations due to policy and institutional differences in vaccination programmes between the countries, such as vaccines being administered by a person other than a doctor, a lack of a physical examination before administration, a lack of choice of vaccine brands, no segregation of sick and health patients at vaccination services, and unease that children did not receive the BCG vaccination (10).

Consent

The use of consent forms for school-based adolescent vaccination programmes was a specific barrier to uptake among adolescents. At face-value, the non-return of consent forms from parents represents the non-acceptance of vaccination, however the underlying reasons are complex. For example, staff members from school-age vaccination teams in London revealed a perception that parents are too busy or time-restricted to complete the forms rather than actively choosing to reject vaccination, while in the South West, the lower return of consent forms was associated with higher levels of deprivation but not with the proportion of vaccines that were actively refused (17, 54). Beyond parental acceptance, a lack of school engagement or support for the HPV vaccination programme was a further barrier; larger schools, those in deprived areas, certain faith schools, and schools where the head teacher does not support the vaccine faced particular challenges (54). This manifested in various ways, such as consent forms not being disseminated, alternative covering letters discouraging vaccination attached to consent forms, and denial of entry to the school (54). A lack of staff time to make phone calls to parents who have not returned consent forms was a further barrier (54).

Activation

Definition: ‘the degree to which individuals are nudged towards vaccination uptake’.

Assessing eligibility

Healthcare professionals’ inability to adequately assess eligibility for vaccinations was an activation barrier for various ethnic minorities. At an individual level, unclear, untranslated or poorly documented vaccination histories were a particular challenge for primary care staff working with adult migrant populations and Bangladeshi parents; the inability to verify vaccinations received overseas resulting in a wariness to deliver repeated doses (8, 9). Additionally, a lack of awareness and/or knowledge of the vaccination catch-up guidelines for adult migrants among primary care staff was a further barrier (9, 35). Discordant guidance on eligibility from the British Society for Rheumatology and JCVI during the study period was cited as a key factor behind the low uptake of the shingles vaccine in a single-centre study of inflammatory arthritis patients (92).

At a population level, the ability to identify the vaccination needs of Roma Romanian communities during measles outbreaks was hindered by the level of vaccination coverage data, potentially hiding ‘pockets’ of lower uptake, compounded by the fact that these communities may not necessarily be registered with a GP or attending school (93). Similarly, interviews with service providers in 4 cities found that lack of routine data collection on Gypsy, Roma and Traveller ethnicity and the slow transfer of immunisation records between data platforms presented barriers to identifying these populations’ vaccination needs (11). Insufficient information transfer between GPs and midwives in some areas of London led to prenatal vaccine discussions being omitted or repeated unnecessarily (5). Directors of Public Health also cited difficulties in identifying disadvantaged populations due to poor quality data more generally (94).

Missed vaccination opportunities

The failure to vaccinate eligible people attending some services or settings capable of administering vaccinations was reported in number of studies. Rates of missed vaccination opportunities among GBMSM attending sexual health services were measured at 22% for hepatitis B, 30% for mpox, and 30% for HPV vaccination (42, 95, 96). A survey of people who inject drugs who were unvaccinated against hepatitis B found that the majority had accessed at least one healthcare service in the preceding year (97). Among a small selective cohort of people with at least one indication for hepatitis B vaccination attending outreach services, such as drug treatment centres and homeless hostels, 41% reported never having been offered vaccination (98). A lack of staff knowledge of the participants and their risk behaviours, as well as possible non-disclosure by the participants of such behaviours due to stigma and negative perceptions, are offered as possible explanations in these studies. In a survey of older adults, while more than 95% had been offered an influenza vaccine, less than two-thirds of respondents reported that they had ever been offered a pneumococcal or shingles vaccine in the last 12 months (39). The reasons for the lack of offer of vaccination in this study is unclear.

Direct recommendation

More positively, recommendation by a trusted healthcare provider was widely cited as a facilitator of vaccination uptake. Trusted providers included midwives among pregnant women, those with a good knowledge of immunosuppressed patients’ conditions, doctors or other respected authority figures (for example, government officials or faith leaders) among adult migrant populations, and one’s GP, from whom a direct invitation or offer of a vaccination was a particularly effective activator (1, 2, 4, 27, 36, 99). Conversely, not receiving a prompt or appointment letter was identified as a barrier to uptake of prenatal vaccinations and vaccinations offered by SHS among GBMSM (43, 44). Among adult migrants and GRT communities, recall and reminder systems, including text invitations, were not universally effective due to a combination of language barriers, transiency of location, and not being registered with a GP (11, 26, 35). Most adult migrants in one study had never been asked about their vaccination histories, whereas most reported that their GP had enquired about the vaccination status of their children (27). Two studies discussed the use of artificial intelligence (AI) technologies in prompting engagement with vaccinations (22, 46). Healthcare providers recognised its potential in disseminating information but had concerns regarding trust, information quality and digital literacy whilst, in a study with pregnant women, AI chatbots were criticised for being clunky, unresponsive, and unable to handle nuanced queries and thus should not replace personal interaction with a healthcare professional (22, 46).

Resource limitations

Resource limitations were also commonly referred to in the literature, most often referring to a lack of staff time and capacity. Insufficient time during individual appointments to discuss vaccination concerns, use an interpreter, encode missing vaccination histories, and to offer opportunistic vaccinations presented barriers to maximising uptake in both primary and antenatal care settings (3, 5, 9, 35). A survey of 82 GPs found that those in urban settings were less likely to report having enough time to provide vaccine recommendations to their elderly patients compared to those in rural settings (99). Local and national policy changes resulting in a loss of capacity, funding and organisational memory, such as the 2013 NHS reforms and cuts to community link workers and health visiting teams, were reported by teams serving Gypsy, Roma and Traveller (11, 93). Evaluation of the 2022 London polio booster campaign highlighted how the universal catch-up offer required resources to be divided between under-vaccinated children, such as in Haredi Jewish communities, and a significantly larger group of fully-vaccinated children thus raising concerns that health inequalities could be inadvertently widened (67).

Interviews with Directors of Public Health, or their representatives, from 21 local authorities revealed that public health teams faced various resource challenges to implementing initiatives with disadvantaged groups (94). These included a lack of funding or a clear route to engage with local communities, a lack of NHS staff capacity to support outreach initiatives, the short notice availability of mobile vaccination units, tensions between achieving national targets versus reaching disadvantaged groups, and a relative lack of local control of vaccination programmes (94).

Workplace factors

Organisational culture and leadership were activation factors alluded to in studies exploring uptake among healthcare workers. Perceptions of higher importance among senior management, greater engagement by Executive Teams, more direct communication strategies such as staff briefings and meetings, facilitating interdepartmental coordination, and framing the programme as a commitment to staff wellbeing were all factors associated with higher overall staff vaccination uptake (24, 100). Workplace factors were also identified in a survey of health and social care workers, with social care workers significantly more likely to have not been offered a vaccine than healthcare workers (86). Participants from Black ethnic groups were also more likely to have not been offered a vaccine than their White counterparts (86). Workplace norms of receiving the vaccination was a facilitator of uptake among care home employees (72).

Social and interpersonal influences

There were numerous reports of how a desire to protect others, particularly close relatives, nudged people towards vaccination uptake. This was prominent among pregnant women seeking to protect their babies against pertussis, which was perceived as more dangerous than influenza, with some demotivated to accept the influenza vaccine due to a belief that this vaccine was for ‘me’ and ‘doesn’t immunise the baby’ (4, 20, 21, 22, 83). In contrast, one study reported how few pregnant women took vaccines for altruistic reasons and some even opposed the framing of messages around altruism (5). However, the protection of others was also cited as a facilitator of vaccination among parents of pre-school children, older adults, and those with chronic respiratory conditions (19, 36, 39).

Viewing vaccination as a social norm within one’s community was a positive influence on uptake, including among parents of pre-school children, Bangladeshi parents, and adolescent girls (8, 36, 54). Among the latter, whilst knowing other girls or older siblings who have received the HPV vaccination was a facilitator, the social impact of others’ negative experiences heightened levels of fear and led some girls to opt-out knowing that others have done so (54). In the same study, knowing someone personally who had been affected by cervical cancer was identified as a facilitator for parents when making their decision regarding consent (54). Separately, positive vaccination experiences among parents of guardians motivated some to encourage others to vaccinate their children while, among at-risk and older adults, knowledge of others’ vaccination statuses or receiving a recommendation by a friend or family member nudged individuals towards uptake (2, 12, 99). In contrast, negative reports from family and friends following vaccinations discouraged some immunocompromised adults (1).

The influence of peers, family and friends was particularly powerful among people from ethnic minorities. Among people seeking asylum and refugees, peers were able to help overcome language barriers, address specific religious and cultural concerns, build trust through shared life experiences and describing their own positive vaccination stories (18). Among some Bangladeshi parents, the role of family and friends was cited as both a positive and negative influence within this tight-knit, family-oriented community; those with positive views encouraged their peers to vaccinate their children, whereas others shared anecdotes relating to side effects and the false link between vaccination and autism (8). Evaluation of the 2022 London polio booster campaign revealed that social networks within the Orthodox Jewish community tended to reinforce the view that vaccination was not necessary (67).

Wider social and interpersonal influences were also found to nudge individuals towards COVID-19 vaccination uptake in several studies. Among ethnically diverse patients from 4 London general practices, if the individual was well-embedded within their community, positive social influences from community or faith leaders acted as facilitators to vaccination uptake (51). Similarly, responses by 130 participants of an online survey supported the theory that people’s strength of identification with their local community would positively predict their ‘willingness to engage in community-related prosocial normative behaviour’, in turn predicting higher levels of vaccination willingness, after controlling for socio-economic status and age (101). There was also evidence that political, as well as social, cohesion supported efficient local COVID-19 vaccination rollout, with politically aligned local authorities (those ‘governed by the same political party as the national government’) reaching 50% vaccination rates more quickly than others (102). However, within such areas, at-risk groups were vaccinated at a similar or slower pace compared to the general population, suggesting a potential trade-off between efficiency and equity (102).

Results of an online survey of students aged 18–35 years showed that the students’ mothers’ vaccine uptake was the most salient predictor of the students’ attitudes towards, and uptake of, COVID-19 vaccination (103). Where students’ had negative relationships with their parents, the best friend’s vaccine uptake superseded the mother’s influence (103). Similarly, receipt of MMR1 appears less likely in children sharing a household with an unvaccinated older child, independent of household size and composition, suggesting strong concordance within households and an increased risk of household transmission (104). There are further examples: parental vaccination intention for a child was associated with social norms regarding vaccination, seeing other community members getting vaccinated was a facilitator to vaccination among Congolese adult migrants, and, among younger adults (aged 18–55 years) belonging to ethnic minorities, the awareness that others within an individual’s social network had been vaccinated served as a cue to vaccination uptake (30, 56, 58, 71, 80).

Suggested interventions

Although interventional studies were not included in this literature review, a number of activation factors were identified as influences on vaccination uptake.

A number of interventions or approaches to improve vaccination were suggested throughout the literature, particularly by those working with ethnic minorities. Working collaboratively and sharing information with agencies outside the health sector were touted as possible interventions for the GRT population, as were joint visits to families, opportunistic immunisation, more flexible appointment systems, and outreach or home vaccination, although the latter was recognised as not encouraging engagement with routine health services (11). Similarly, those working with Roma Romanian communities advocated for community engagement using a multi-faceted approach including door-to-door knocking, mobile vaccination vans, offering vaccination in community centres, language-appropriate communication, and involving members of the community as vaccine advocates (26, 93).

Among Bangladeshi parents and their healthcare providers, proactive communication including regular appointment reminders, efficient systems to flag missed vaccinations to HCWs, using the Personal Child Health Record (‘Red Book’) as a tool for tracking a child’s immunisations and upcoming appointments, and the transparency regarding ingredients and provision of information for alternative vaccines as a means to navigate religious concerns, were all considered effective strategies (8). Parents in a more deprived and ethnically diverse area of London also found that the Red Book served as an important activation factor for childhood vaccinations, particularly when they did not receive reminders from their GP (7). Suggestions of how to overcome language and cultural barriers included maximising the cultural and linguistic competence of an ethnically diverse workforce and tailoring interventions to align with specific populations customs and practices (8, 67).

Running catch-up clinics, emphasising the financial value of vaccinations, and feeding back to schools on their performance were some of the activation methods used to promote uptake by school-aged vaccination teams in London (54). Various suggestions were made to overcome the non-return of consent forms including taking verbal consent, the use of electronic consent forms, adopting an opt-out approach, and the active involvement of school staff (54, 91). Self-consent was perceived as requiring extra time and resources and not all providers felt confident in assessing for ‘Gillick competency’; some schools were also unsupportive of this practice and cited difficulties in negotiating situations where adolescents’ cultural heritage may inhibit their ability to provide self-consent due to a perception that the decision is deemed the parents’ responsibility (91).

Semi-structured interviews with 15 health professionals and 6 community leaders and lay members in a largely rural and remote coastal county, identified several initiatives that were believed to have improved COVID-19 vaccination coverage (105). These included targeted data-informed public health messaging, partnerships between local organisations and trusted community members with the NHS and public health, using both traditional and social media flexibly, and increasing the physical access via the provision of transport (for example, shuttle buses) and mobile pop-up vaccination centres (105). Interviews conducted with professional, community and religious representatives exploring COVID-19 vaccination delivery among the Haredi Jewish population in London found that a co-delivery model alongside an Orthodox Jewish health organisation was seen as a vehicle to mediate trust, signalling the benefit of a localised approach for minorities with historically suboptimal vaccination coverage (106, 107).

However, some attempts to increase uptake were viewed as ‘coercive’, such as the public discourse around mandatory vaccination for certain professions, and cited as factors involved in driving vaccine hesitancy (72, 57).In one study with 10 unvaccinated care home employees in the North West, most participants indicated favouring leaving their job over getting vaccinated (72). Similarly, in a cross-sectional survey of over 1,500 healthcare and over 250 social care workers, feeling pressured by an employer to receive a vaccination was associated with a greater likelihood of refusal (86). The coercive nature of public messaging more broadly was also identified as a barrier to uptake (30, 76).

The use or lack of incentives were also referred to in a number of studies. NHS Trusts with high uptake of the influenza vaccine among healthcare workers were more likely to report setting higher uptake targets and offering significantly more incentives such as food and drinks vouchers to staff receiving a vaccination (100). In contrast, lower uptake Trusts were associated with the use of negative or coercive arguments and practices, such as equating declining vaccination to a breach of codes of conduct, using opt-out forms, and ‘naming and shaming’ wards with low uptake (24). Similarly, among adults with chronic respiratory conditions, undue pressure from healthcare professionals to receive the influenza vaccination exacerbated participants’ feelings of uncertainty about the vaccine and of being undermined as autonomous individuals (19).

In a study investigating parents’ views on mandatory vaccinations, the most influential factors were direct financial rewards including financial incentives for vaccination, imposing penalties for missing a dose, and a compensation scheme for those who experience severe adverse side effects (108). However, ethnic minorities showed different preferences to White participants, placing more importance on the ability to opt out and a preference for schemes allowing medical and religious belief exemptions (108). Among mothers who have rejected some or all of their child’s routine vaccinations, there was a sense of fear among participants that vaccines would become mandatory in schools, a fear potentially heightened by the pandemic, and feelings of being targeted for holding a minority opinion (47). A lack of incentivisation, including financial reimbursement, via schemes such as the Quality Outcomes Framework (QOF) was identified in interviews with primary care professionals as an activation barrier among adult migrants (9). In the context of the wider social restrictions implemented as part of the response to the COVID-19 pandemic, a desire to ‘return to normal’ was another commonly cited incentive of vaccination uptake. This included wanting to maintain regular activities, to avoid social and travel restrictions, and to be able to visit older relatives (14, 15, 58, 69, 74, 106).

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80. Smith LE, Sim J, Cutts M, and others. ‘Psychosocial factors affecting COVID-19 vaccine uptake in the UK: A prospective cohort study (CoVAccS – Wave 3)’ Vaccine: X 2023: volume 13, page 100276

81. Gallant AJ, Nicholls LAB, Rasmussen S, and others. ‘Changes in attitudes to vaccination as a result of the COVID-19 pandemic: A longitudinal study of older adults in the UK’ PLOS ONE 2021: volume 16, issue 12, article e0261844

82. Sethi S, Kumar A, Mandal A, and others. ‘The UPTAKE study: a cross-sectional survey examining the insights and beliefs of the UK population on COVID-19 vaccine uptake and hesitancy’ BMJ Open 2021: volume 11, issue 6, article e048856

83. Anderson E, Brigden A, Davies A, and others. ‘Maternal vaccines during the Covid-19 pandemic:A qualitative interview study with UK pregnant women’ Midwifery 2021: volume 100, page 103062

84. Wilcox CR, Calvert A, Metz J, and others. ‘Attitudes of Pregnant Women and Healthcare Professionals Toward Clinical Trials and Routine Implementation of Antenatal Vaccination Against Respiratory Syncytial Virus: A Multicenter Questionnaire Study Pediatric Infectious Disease Journal 2019: volume 38, issue 9, pages 944 to 951

85. Stead M, Jessop C, Angus K, and others. ‘National survey of attitudes towards and intentions to vaccinate against COVID-19: implications for communications’ BMJ Open 2021: volume 11, issue 10, article e055085

86. Bell S, Clarke RM, Ismail SA, and others. ‘COVID-19 vaccination beliefs, attitudes, and behaviours among health and social care workers in the UK: A mixed-methods study PLOS ONE 2022: volume 17, issue 1, article e0260949

87. Chaudhuri K, Chakrabarti A, Chandan JS, and others. ‘COVID-19 vaccine hesitancy in the UK: a longitudinal household cross-sectional study’ BMC Public Health 2022: volume 22, issue 1, page 104

88. Allington D, McAndrew S, Duffy B, and others. ‘Trust and experiences of National Health Service healthcare do not fully explain demographic disparities in coronavirus vaccination uptake in the UK: a cross-sectional study BMJ Open 2022: volume 12, issue 3, article e053827

89. Paul E, Fancourt D, Razai M. ‘Racial discrimination, low trust in the health system and COVID-19 vaccine uptake: a longitudinal observational study of 633 UK adults from ethnic minority groups’ Journal of the Royal Society of Medicine 2022: volume 115, issue 11, pages 439 to 447

90. Woodhead C, Juliana O, Rebecca R, and others. ‘Race, ethnicity and COVID-19 vaccination: a qualitative study of UK healthcare staff’ Ethnicity and Health 2022: volume 27, issue 7, pages 1,555 to 1,574

91. Chantler T, Letley L, Paterson P, and others. ‘Optimising informed consent in school-based adolescent vaccination programmes in England: A multiple methods analysis’ Vaccine 2019: volume 37, issue 36, pages 5,218 to 5,224

92. Ahmed S, Lauran M, Ugwoke A, and others. ‘The relationship between Zoster serology, vaccination uptake and infection rates: a single-centre cross-sectional study’ Rheumatology Advances in Practice 2024: volume 8, issue 4

93. Bell S, Saliba V, Evans G, and others. ‘Responding to measles outbreaks in underserved Roma and Romanian populations in England: the critical role of community understanding and engagement’ Epidemiology and Infection 2020: volume 148, article e138

94. Lecouturier J, Kelly MP, Sniehotta FF. ‘Reaching national Covid-19 vaccination targets whilst decreasing inequalities in vaccine uptake: Public health teams’ challenges in supporting disadvantaged populations Public Health in Practice 2024: volume 8, page 100551

95. Baldry G, Phillips D, Wilkie R, and others. ‘Factors associated with human papillomavirus, hepatitis A, hepatitis B and mpox vaccination uptake among gay, bisexual and other men who have sex with men in the UK– findings from the large community-based RiiSH-Mpox survey’ International Journal of STD and AIDS 2024: volume 35, issue 12, pages 963 to 981

96. Mullen D, Edney J, Phillips D, and others. ‘Mpox vaccination uptake in a UK community sample of gay, bisexual and other men who have sex with men (GBMSM) the year following the 2022 clade IIb mpox outbreak Sexually Transmitted Infections 2025: volume 101, issue 3, pages 203 to 204

97. Njoroge J, Hope VD, O’Halloran C, and others. ‘Are there missed opportunities for vaccinating against hepatitis B among people who inject drugs in the UK?’ Epidemiology and Infection 2019: volume 147, article e244

98. Taylor JEB, Surey J, MacLellan J, and others. ‘Hepatitis B vaccination uptake in hard-to-reach populations in London: a cross-sectional study’ BMC Infectious Diseases 2019: volume 19, issue 1, page 372

99. Bricout H, Torcel-Pagnon L, Lecomte C, and others. ‘Determinants of shingles vaccine acceptance in the United Kingdom’ PLoS One 2019: volume 14, issue 8, article e0220230

100. Stead M, Critchlow N, Patel R, and others. ‘Improving uptake of seasonal influenza vaccination by healthcare workers: Implementation differences between higher and lower uptake NHS trusts in England Infection, Disease and Health 2019: volume 24, issue 1, pages 3 to 12

101. Wakefield JRH, Khauser A. ‘Doing it for us: Community identification predicts willingness to receive a COVID-19 vaccination via perceived sense of duty to the community’ Journal of Community and Applied Social Psychology 2021: volume 31, issue 5, pages 603 to 614

102. Sohns F, Ghinoi S, Langosch M. ‘The effect of public tolerance towards corruptive behaviour on healthcare efficiency and equity - The case of the UK’s COVID-19 vaccination programme Social Science and Medicine 2024: volume 361, page 117180

103. Thompson O, Cristea M, Tamariz M. ‘COVID-19 vaccination attitudes and uptake: A sociocultural perspective focusing on parents and peers’ PLOS ONE 2024: volume 19, issue 7, article e0300771

104. Marszalek M, Firman N, Wilk M, and others. ‘Household determinants of delayed MMR vaccination: longitudinal analysis using electronic health records in North East London, UK BMJ Open 2025: volume 15, issue 5, article e097559

105. Nanyonjo A, Nelson D, Sayers E, and others. ‘Community efforts to promote vaccine uptake in a rural setting: a qualitative interview study’ Health Promotion International 2023: volume 38, issue 4

106. Kasstan B, Letley L, Mounier-Jack S, and others. ‘Tailoring immunisation programmes in a time of SARS-CoV-2: What can be learnt by comparing the findings of childhood and COVID-19 vaccine evaluation studies in an underserved population?’ Public Health in Practice 2022: volume 4, page 100287

107. Kasstan B, Mounier-Jack S, Letley L, and others. ‘Localising vaccination services: Qualitative insights on public health and minority group collaborations to co-deliver coronavirus vaccines Vaccine 2022: volume 40, issue 14, pages 2,226 to 2,232

108. Smith LE, Carter B. ‘Parental preferences for a mandatory vaccination scheme in England: A discrete choice experiment’ The Lancet Regional Health: Europe 2022: volume 16 (no pagination)