Closing the pertussis immunisation gap in Liverpool

Increasing pertussis (whooping cough) immunisation uptake amongst women in the asylum system or with English as an additional language

Pertussis (whooping cough) is a particularly lethal disease for infants, and it is preventable by immunisation during pregnancy. Across Liverpool, women in the asylum system or with English as an additional language are far less likely to be immunised during pregnancy than women in the general population.

To work towards closing this gap, Liverpool Lighthouse partnered with the Creative Influencers – providing the voice of lived experience – and Liverpool Women's Hospital, Public Health, Brownlow Health, Anfield & Everton PCN, ReCITE, LSTM and the University of Liverpool.

The problem

• Local uptake among women in the asylum system or with English as an additional language was 34%, compared with 66% nationally

• Nationally, women in the asylum system or with English as an additional language are almost twice as likely not to have the pertussis vaccine as the general population

• 10 babies died of whooping cough in England in 2024 (none in 2023)

• National research attributed low uptake to a lack of trust in the vaccine, alongside cultural reasons

The research

Data capture included 118 surveys with women in the asylum system or with English as an additional language, 23 surveys with midwives, and one focus group with health professionals, with results concluding:

• 79% had heard of whooping cough, with 69% needing more information, and 69% not being advised how to get the vaccine.

• For 62%, immunisation was their own decision; for 30% it was a shared decision.

• Components leading to non-immunisation included inadequate information, pertussis being mentioned alongside other vaccines, and barriers to accessing it.

• Motivating factors included a desire to protect baby's health, and a recommendation from a doctor or midwife.

Root causes

Some causes are systemic. Refugees and asylum seekers are not a health priority, often facing a hostile environment within a health system not set up for them, with no review of what needs tailoring for women, and a lack of finance.

Others were more immediately fixable: a lack of knowledge of what whooping cough can do to a baby, multiple vaccines offered at once, no appointment given, and women not told where to go for immunisation. Money for travel and digital exclusion also acted as a blocker, alongside a language barrier, and data poorly shared between the hospital and GPs. Health staff had limited training on race and the asylum experience, leaving biases and assumptions unaddressed.

Actions to close the gap

A number of assets and interventions were developed:

• A one-minute film with a simple, emotionally engaging message, shown on screens at Liverpool Women's Hospital

• A pregnancy journey poster in five languages, with tips from lived experience and QR codes for support, provided at the booking appointment

• Midwife-led discussions about pertussis at 16 weeks; and on-site immunisation at the 20-week scan

• Scan letters were updated to include pertussis information

• A pictorial to support appointment access was produced using hospital-styled graphics

• EMIS and hospital data were aligned, with language, ethnicity and sanctuary status made mandatory fields

• For health professionals, the When You Know: Childbirth in the Asylum System film illustrates the asylum experience, with a reflective template to work through afterwards

Results so far

• Uptake among women in the asylum system or with English as an additional language rose from 22.4% to 31.2% over six months

• A 39.4% relative increase in pertussis uptake

• A 24.7% relative increase across the hospital trust

• Increased attendance at appointments at the hospital

Nationally, women in the asylum system or with English as an additional language remain almost twice as likely not to have the pertussis vaccine. At Liverpool Women's Hospital, these women are now 30% more likely to have it.

Initial project impact

This health project has had significant influence both locally and nationally:

• 100% of undergraduate midwives trained in Liverpool and Ormskirk are trained in the asylum experience

• All midwives at Liverpool Women's Hospital watch the film with resources

• The film is endorsed by the Royal College of GPs and the Royal College of Midwives

• National work to change the date beyond which pregnant asylum seekers cannot be moved, to earlier in pregnancy

• National work on improving access to pharmacy

The impact beyond Liverpool

We are delighted to see the success achieved in Liverpool gaining momentum further afield and across a wider range of health initiatives:

• Four years of assets, with the film shared locally and nationally

• The ICB has agreed to share project resources

• Public Health Liverpool has shared the assets with other boroughs

• NHS England is in communication about sharing the resources

• The model of practice is being replicated with a cervical screening project

• Creative Influencers are on a Creative Health leadership programme, with four years of funding for eight creative health projects