Identifying parental reasons for MMR1 vaccine hesitancy or acceptance: A quantitative, cross-sectional survey in Liverpool using the 5As model of vaccine acceptance

Public Health Dissertation Prize Winner


  • Katherine Davis


MMR, measles, parents, Liverpool, vaccine hesitancy, determinants, 5A taxonomy


Measles is a globally prevalent, vaccine preventable disease which is highly contagious and potentially deadly. Those most at risk are young children and unimmunized people (ECDC, 2022). Worldwide, measles cases declined by 83% during 2000-2017 (WHO, 2018), but measles vaccine coverage is inconsistent and below the World Health Organisation’s recommended 95% at population level, for public protection and disease eradication (WHO, 2021). In the UK, the free Measles Mumps and Rubella (MMR) vaccine is routinely offered in childhood (NHS, 2019) but national MMR vaccine coverage is below 95%. Some local authorities such as Liverpool, have experienced a larger decline in MMR uptake compared to others (2013, 94.7%, 2022, 82.1%) (NHS Digital, 2022). Vaccine hesitancy is considered the main reason for declining MMR1 uptake (WHO, 2020) and is largely driven by lack of confidence in the vaccine and a retracted link between the MMR vaccine and autism in the 1990’s (Tannous, Barlow and Metcalfe, 2014). UK MMR campaigns intending to increase vaccine uptake focus on raising public confidence, but this is one hesitancy factor which is not sympathetic to local nuances. Identifying the reasons for MMR vaccine hesitancy in local populations and tailoring MMR vaccine programme delivery according to need, is the most effective way to increase vaccine uptake and close vaccine gaps (PHE, 2021). This study explores Liverpool parents’ reasons for MMR1 vaccine acceptance, refusal or delay using the 5A model of non-sociodemographic factors relating to vaccine uptake. Using the same 5A model, it explored the lesser researched impact of parent's income and education on their MMR vaccine acceptance. The study population was sampled using non-probability and convenience methods and empirical data was collected by anonymous online questionnaire. Problems with recruitment resulted in a low study sample (N=28) and findings have potential to be impacted by over and under representation and non-response bias. The low quantity of study data prevented any significant statistical analysis of study findings, and the robustness and validity of results is therefore uncertain. No data was received from participants who refused the MMR vaccine, which limited full exploration of the study question. Findings largely concurred with previous studies and perceived confidence in the vaccines safety and effectiveness was a predictor of overall vaccine acceptance in Liverpool. Although not statistically confirmed, findings suggest university education, and not higher income is a predictor of timely MMR1 vaccine receipt. Generally, statement responses observed a relationship between participants of university education and participants of higher income. The influence of peers and the functionality of prompts did not follow this trend and a more complex socioeconomic relationship may exist in Liverpool. The 5A statement set was effective at exploring the topic but this study will need to be replicated in similar cities with a larger study sample for the findings of this study to have relevance to Liverpool. The researcher recommends future MMR vaccine hesitancy research should investigate the importance of university education on parent's reasons for accepting MMR1 as there is a potential link between formal education and peer influence.