From data to delivery: a health equity approach to improving Measles, Mumps and Rubella (MMR) uptake through primary care in Hull

Like many areas nationally, Hull has faced ongoing challenges with childhood vaccination uptake, particularly with Measles, Mumps and Rubella (MMR) vaccination. Whilst declining uptake remained a broader national concern, local intelligence suggested that patterns of under-vaccination within Hull were not evenly distributed across the population. Emerging evidence indicated that some communities may be experiencing disproportionate barriers to access, engagement and timely vaccination.

Rather than implementing a broad, universal awareness campaign alone, the Hull City Council Public Health Team initiated a Health Equity Audit (HEA) to better understand variation in MMR uptake across local populations and to identify where inequalities were emerging within the system.

The work aligned with the NHS Core20PLUS5 approach and utilised a Health Equity Assessment Tool (HEAT) - informed methodology to examine uptake across deprivation, ethnicity, language and geographical patterns. Importantly, the work drew upon granular

Primary Care Network (PCN) level intelligence and operational service insight, enabling the system to move beyond headline uptake figures and towards a more detailed understanding of where barriers may exist.
This subsequently developed into a multi-agency, intelligence-led programme of work that sought not only to describe inequalities, but to operationalise practical equity-focused vaccination improvement approaches within existing primary care systems.

The programme was overseen through the Hull MMR Steering Group, bringing together representatives from Hull City Council Public Health, the NHS England Humber and North Yorkshire Screening and Immunisation Team, Humber and North Yorkshire Integrated Care Board (ICB), Child Health Information Services (CHIS), participating Primary Care Networks and wider vaccination partners.

Much of the pilot work sat outside routine contractual requirements and therefore relied upon strong collaboration, trust and a shared commitment to improving equitable vaccination uptake.

The governance structure enabled ongoing dialogue between public health intelligence, primary care delivery and system-wide vaccination improvement priorities, supporting iterative learning as the work progressed.

The HEA identified several recurring themes associated with lower uptake, including language barriers, inconsistent recording of communication needs, mobility within some communities and variation in recall processes across practices.

In response, the Public Health Team worked collaboratively with PCNs to develop a multilingual behavioural reminder pilot embedded within existing recall systems. Rather than creating parallel services, the intervention aimed to strengthen and adapt existing operational pathways using a more targeted and equity-focused approach.

The pilot included:

• translated behavioural reminder letters
• structured “three-contact” recall pathways
• text message and telephone follow-up
• direct appointment offers
• and standardised approaches to identifying children with incomplete MMR vaccination.

Participating PCNs utilised local intelligence relating to language, ethnicity, deprivation and registration patterns to support delivery of the pilot. Translation support was developed across a broad range of identified languages within the under-vaccinated populations in Hull which included Romanian, Arabic, Kurdish, Polish, Somali, Tigrinya and Farsi.

The programme highlighted the importance of searchable language coding, data quality and consistent recording of communication needs

One of the most important findings from the work was that improving equitable vaccination uptake requires more than translation alone.

Participating PCNs identified a range of practical and operational factors influencing engagement. These included incomplete or inconsistent recording of spoken language, incorrect or outdated contact details, periods of travel outside the UK leading to missed vaccination windows, and the workload implications for GP practices associated with enhanced recall processes

Participating PCNs identified that spoken language was not always recorded using searchable coded fields. In some cases, language needs were recorded as free text or administrative alerts, which could not be systematically searched within the clinical record. This limited the ability to identify families who may benefit from translated communication and emerged as one of the most important operational learning points from the pilot. Practices also reported difficulties contacting some families due to mobile numbers no longer being in service, as well as periods of travel outside the UK, leading to missed vaccination windows.

The work also highlighted the importance of checking vaccination coding quality. Practices identified that some children had received both MMR doses, but both entries had been coded as MMR1 rather than MMR1 and MMR2. This meant that some children appeared incompletely vaccinated until records were reviewed in more detail.

This finding reinforced the need for data quality review alongside any population health management approach to immunisation.
Importantly, the work also reinforced the value of embedding interventions within existing trusted primary care systems rather than creating separate parallel processes. Practices reported that translated communication could be integrated relatively easily into existing workflows once operational systems had been adapted.

Early outcome data also provided encouraging signals of improvement. One participating Primary Care Network reported a reduction in the number of children aged six years and under recorded as having incomplete MMR vaccination, from 2,249 children between January–April 2025 to 2,146 children during the equivalent period in 2026, representing 103 fewer children recorded as incompletely vaccinated. Whilst multiple factors may influence vaccination uptake and causality cannot be assumed from these early data alone, the findings provide reassurance that intelligence-led, targeted approaches can be successfully implemented within routine primary care systems and may contribute to improved vaccination coverage.

One participating practice reflected that:

Translated communication helped us engage families whose first language was not English. The approach integrated easily into existing recall processes and staff adapted quickly to using the translated letters.”

Another important area of learning related to sustainability and scalability. Whilst practices reported positive experiences integrating translated communication into recall systems, operational capacity remained a significant consideration. Offering appointments at the point of invitation and undertaking repeated follow-up can create additional pressure for already highly utilised practice nursing and administrative teams, particularly where non-attendance rates remain high.

The Hull programme demonstrates how councils, public health teams and primary care systems can move beyond broad universal messaging and instead operationalise equity-focused vaccination improvement using local intelligence.

Importantly, the approach was:

• embedded within existing systems
• scalable across PCNs
• governance-led
• and capable of adaptation across different local contexts.

A major strength of the programme was the ability to translate formal Health Equity Audit methodology into practical operational delivery. The work moved beyond describing inequalities and instead tested how granular public health intelligence could be used to shape vaccination pathways within primary care.

At a time when national systems continue to face challenges relating to declining childhood vaccination uptake and widening inequalities, the Hull approach offers a practical example of how local intelligence, partnership working and targeted operational design can be combined to support more equitable immunisation delivery.

The programme also needs to remain responsive to changes in the national childhood immunisation schedule. The introduction of MMRV may bring additional communication challenges, particularly where parents have questions about the varicella element of the vaccine.

National guidance and translated resources developed by UKHSA and partners will be important in supporting practices to respond consistently and confidently to parental queries.

The next phase of the programme will focus on further implementation learning, continued evaluation of operational outcomes and explore additional community insight and engagement approaches to better understand persistent barriers within under-vaccinated groups.

• Health Equity Audits can help move systems beyond headline vaccination uptake figures and identify where inequalities are concentrated. 
• Local primary care intelligence can provide valuable insight into barriers affecting specific communities. 
• Language recording and data quality are critical foundations for equitable vaccination delivery. 
• Embedding interventions within existing primary care recall systems may be more sustainable than creating parallel processes. 
• Strong partnership working between local councils, NHS England, ICBs and primary care can help translate intelligence into practical action.

Dr Thiru Murgappan, MD., MPH 

Health Inequalities Fellow, Humber & North Yorkshire ICB and Health Protection Program Lead, Hull City Council

Email: [email protected]