title: Acceptability of financial incentives or quasi-mandatory schemes to increase uptake of immunisations in preschool children in the United Kingdom: Qualitative study with parents and service delivery staff.
abstract: BACKGROUND
  Since the 1990 s strenuous attempts have been made to rebuild trust in childhood immunisations. This study aimed to understand if financial incentives (FI) or quasi-mandatory schemes (QMS), e.g. mandating immunisations for entry to universal services such as day care or school, might be acceptable interventions to increase immunisations uptake for preschool children.
  
  
  METHODS
  Parents and carers of preschool children (n=91); health and other professionals (n=18); and those responsible for developing and commissioning immunisation services (n=6) took part in the study. Qualitative methods were employed to explore the acceptability of FI/QMS with stakeholders. Framework analysis was used to develop a coding framework that was applied to the whole dataset. Interpretations of the emergent themes were verified between researchers and presented to the project's Parent Reference Group to ensure coherence and relevance.
  
  
  RESULTS
  (1) FI: parents and professionals felt introducing FI was inappropriate. It was acknowledged FI may encourage families living in disadvantage to prioritise immunisation, but unintended consequences could outweigh any advantage. FI essentially changes behaviour into a cash transaction which many equated to bribery that could inadvertently create inequalities. (2) QMS: parents and professionals highlighted the positives of introducing QMS, stating it felt natural, fair and less likely to create inequality. Despite QMS' potential to positively impact on uptake there were concerns about the implementation and workability of such schemes.
  
  
  CONCLUSIONS
  FI for preschool immunisation may not be acceptable, within a UK context. Introducing FI could have detrimental effects on uptake if it were associated with bribery and coercion. Quasi-mandatory schemes, mandating immunisation for universal service entry, was the most acceptable option and could contribute to the normalising of immunisation. Future work would be needed to assess how this could be successfully implemented and if it did indeed increase uptake.
authors.affiliation: Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough TS1 3BA, United Kingdom; Fuse (UKCRC Centre for Translational Research in Public Health), Newcastle University, Newcastle-upon-Tyne NE2 4AX, United Kingdom. Electronic address: R.McNaughton@tees.ac.uk.
authors.forename: Rebekah Jayne
authors.initials: RJ
authors.lastname: McNaughton
authors.affiliation: Fuse (UKCRC Centre for Translational Research in Public Health), Newcastle University, Newcastle-upon-Tyne NE2 4AX, United Kingdom; Centre for Diet and Activity Research (CEDAR), MRC Epidemiology Unit, University of Cambridge, Cambridge CB2 0QQ, United Kingdom. Electronic address: jma79@medschl.cam.ac.uk.
authors.forename: Jean
authors.initials: J
authors.lastname: Adams
authors.affiliation: Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough TS1 3BA, United Kingdom; Fuse (UKCRC Centre for Translational Research in Public Health), Newcastle University, Newcastle-upon-Tyne NE2 4AX, United Kingdom. Electronic address: J.Shucksmith@tees.ac.uk.
authors.forename: Janet
authors.initials: J
authors.lastname: Shucksmith
mesh_terms: D002675:Child, Preschool; D006282:Health Personnel; D006293:Health Promotion / Q000191:economics / Q000379:methods*; D006801:Humans; D037141:Mandatory Programs; D009042:Motivation; D010290:Parents; D036301:Qualitative Research; D012201:Reward; D006113:United Kingdom; D014611:Vaccination / Q000191:economics / Q000523:psychology*
keywords: Childhood immunisation; Financial incentives; Quasi-mandatory schemes