The report brings together evidence, policy perspectives, and practical experience from leading experts across public health, clinical practice, social science, civil society, and policy, all focused on a critical question: why do vaccination inequities persist, and what will it take to fix them? The answer that emerged is clear: Vaccination inequities are not accidents. They are predictable, patterned, and preventable outcomes of how systems are designed, measured, and experienced.
1.
The Vaccination Equity session of the 2025 LifeCourse Prevention Summit convened to examine why significant inequities in vaccination uptake and protection persist, despite the availability of safe and effective vaccines and longstanding policy commitments to universal immunization. The meeting brought together experts from public health, clinical practice, social science, civil society, and policy organizations to explore how vaccination systems function in practice for underserved populations.
A central aim of the meeting was to move beyond descriptive accounts of unequal outcomes and to interrogate the system-level drivers that produce and sustain inequity. Participants were invited to consider not only where gaps exist, but how data systems, service design, governance structures, and engagement approaches contribute to those gaps.
Framing remarks by the meeting's Chair emphasized the urgency of addressing vaccination inequity as part of a broader LifeCourse prevention agenda. Speakers throughout the session highlighted that inequities in childhood vaccination have implications well beyond immediate disease risk, shaping health trajectories, trust in institutions, and cumulative disadvantage over time.
The meeting therefore sought to:
A consistent theme across the briefings was that vaccination inequity cannot be adequately explained by individual attitudes, gaps in information, or isolated instances of refusal. Instead, speakers emphasized that inequities are produced by the interaction of system design, social conditions, and institutional practice.
Evidence presented during the session demonstrated that system-level factors—including how services are organized, how success is measured, how resources are allocated, and how communities are engaged—shape who is reached by vaccination programs and who is left behind. Structural inequalities such as poverty, housing insecurity, and unequal access to services were shown to translate directly into unequal vaccination outcomes, even in settings where vaccines are provided free of charge.
Speakers also highlighted that trust in vaccination is inseparable from trust in institutions. Where systems are experienced as inconsistent, inaccessible, or unresponsive, mistrust can emerge as a rational response to lived experience rather than an expression of individual reluctance. In this context, under-vaccination reflects broader power relations and moral economies that influence how authority, responsibility, and risk are perceived.
By situating vaccination equity within these wider system dynamics, the meeting established a foundation for examining evidence and policy responses that address root causes rather than symptoms.
2.
The meeting challenged the widespread reliance on "vaccine hesitancy" as a primary explanatory framework for unequal vaccination uptake. Speakers cautioned that the term is often used imprecisely, grouping together diverse experiences such as access barriers, delayed vaccination, partial uptake, and mistrust under a single behavioral label.
Evidence presented showed that framing under-vaccination as hesitancy risks:
Speakers emphasized that decisions about vaccination are shaped by social norms, institutional experiences, and material constraints. In many cases, what is described as hesitancy reflects the difficulty of navigating systems, rather than opposition to vaccination itself. Reframing the problem away from individual behavior was identified as a necessary step for designing effective and equitable interventions.
A key distinction between equality and equity in vaccination was discussed by speakers, who shared that providing the same services to all populations does not guarantee equitable outcomes, particularly in contexts of social and economic inequality.
Evidence showed that "equal" delivery models—such as standard clinic hours, uniform communication strategies, or one-size-fits-all pathways—often advantage those with greater resources and capacity to navigate systems, while disadvantaging those facing poverty, instability, or exclusion. As a result, equality in service delivery does not guarantee equity in protection.
The principle of proportionate universalism emerged as a framework for addressing this challenge: maintaining universal vaccination programs while tailoring intensity and support according to level of need. This approach was linked to engagement models, co-designed interventions, and flexible delivery strategies that respond to diverse circumstances.
By clarifying this distinction early in the report, the meeting established a conceptual basis for the evidence and actions presented in subsequent sections, reinforcing the need to design vaccination systems that actively reduce—rather than inadvertently reproduce—inequity.
3.
Key question: What are we failing to see?
A central theme that emerged from the expert briefings was that current vaccination data systems systematically underestimate inequity, creating blind spots that delay or misdirect policy action. Speakers emphasized that while headline coverage figures may appear reassuring, they frequently mask deep, persistent, and predictable inequalities affecting specific population groups. [Fig.1]
Several contributors highlighted that national and regional vaccination coverage statistics are typically reported as single averaged figures, which obscure substantial variation within populations. These aggregate indicators often fail to capture:
As a result, systems may be classified as "high performing" while still allowing clusters of vulnerability to persist, increasing the risk of outbreaks and avoidable disease burden. These patterns are also evident across deprivation groups and over time. [Fig.2]
Childhood Vaccination Coverage by Age and Population Group
Stein-Zamir C et al., 2019
This chart shows that relying on final vaccination coverage alone can obscure important inequities in immunization performance. Although cumulative MMR1 coverage among the ultra-Orthodox population approaches that of other groups by 36–48 months of age, uptake is substantially delayed during the early months of eligibility. This period corresponds to a critical window of vulnerability, when susceptibility to measles is highest. By failing to routinely monitor vaccination timeliness, immunization programs may overlook delayed protection and underestimate outbreak risk, even in settings where overall coverage appears high. (Adapted from Stein-Zamir C, Israeli A., Euro Surveillance, 2019;24(6):1800004).
Widening Inequalities in Childhood Vaccination Uptake: Evidence from GP Practice-Level Data, 2019–2023
Flatt A et al., medRxiv, 2024
This figure depicts population weighted uptake of each vaccination studied over time, stratified by Index of Multiple Deprivation (IMD) decile. It demonstrates widening social gradient in childhood vaccination uptake in England, with coverage consistently lower in more deprived areas across all vaccines shown. The decline accelerated during and after the COVID-19 period, particularly for MMR at ages 2 and 5, with MMR2 coverage falling well below the WHO 95% target in all deprivation groups. The gradient indicates a systemic failure, reflecting the impact of rising child poverty and reduced investment in preventative services on equitable vaccine delivery. (Adapted from Flatt A et al., Inequalities in childhood vaccine uptake: a longitudinal analysis of national coverage in England 2019–23, medRxiv, 2024; https://doi.org/10.1101/2024.02.03.24302193.)
Evidence presented during the session highlighted persistent limitations in the level of detail of routinely collected immunization data. [Fig.3] In many settings, data systems do not systematically capture information on:
This lack of detail limits policymakers' and service planners' ability to identify where along the vaccination pathway exclusion occurs. Participants noted that without this level of insight, health systems are constrained in their ability to anticipate gaps. Inequities are often detected only after outbreaks or declines in uptake, rather than prevented through proactive system design.
Childhood Vaccination Completion Pathway by Ethnic Group
Tiley KS et al., Vaccine, 2018
This figure shows vaccination coverage of children at five years of age by ethnic group for children born April 2001 to March 2006, London. High initiation rates mask significant inequities in course completion, with drop-out increasing disparities across ethnic groups as vaccination schedules progress. (Adapted from Tiley KS et al., Vaccine, 2018;36(45):6726–6735.)
Speakers emphasized that what is measured — and what is not — directly influences policy decisions. By focusing primarily on overall uptake, health systems may:
The discussion highlighted that data gaps are not neutral; they can unintentionally reinforce inequity by rendering some populations statistically invisible. This issue was also linked to broader decision-making frameworks, in which equity considerations are often treated as secondary to efficiency or cost-effectiveness, rather than as core performance criteria.
The evidence presented demonstrates that improving vaccination equity requires reform of measurement and delivery systems. Participants underscored the need for:
Without such reforms, inequities remain predictable yet insufficiently addressed, limiting the effectiveness of both policy interventions and community-level solutions.
Key question: Why do barriers to vaccine access persist?
Evidence presented during the meeting consistently demonstrated that barriers to vaccination access are rooted in structural and socioeconomic conditions, rather than individual reluctance or lack of awareness. Speakers emphasized that many families experience vaccination systems as inflexible, burdensome, and poorly aligned with their lived realities, particularly in contexts of poverty, social exclusion, and service fragmentation.
A recurring theme across the briefings was the role of poverty as a fundamental determinant of vaccination inequity. Evidence highlighted that families experiencing economic hardship face multiple, compounding barriers, including:
These constraints disproportionately affect families living in deprived areas and contribute to delayed, interrupted, or missed vaccination, even in systems where vaccines themselves are provided free of charge. Speakers stressed that such barriers are often invisible in policy discussions that assume equal capacity to engage with services, reinforcing the misconception that access is universal when, in practice, it is not.
Beyond material constraints, the evidence showed that administrative processes and service design choices can themselves function as exclusionary mechanisms. Participants highlighted common barriers such as:
These features disproportionately affect families already under strain and can result in missed opportunities for vaccination, particularly when services fail to adapt to the realities of marginalized populations. Speakers noted that such barriers are often unintended but are nonetheless predictable outcomes of systems designed around institutional convenience rather than user need.
Evidence also pointed to the impact of long-term underinvestment in preventive services, particularly in deprived areas. Speakers described how reductions in funding for public health, community outreach, and primary care capacity have:
As a result, families with greater resources are often better able to compensate for system shortcomings, while those facing socioeconomic disadvantage are left increasingly exposed to access gaps. This dynamic was described as a key mechanism through which inequality becomes entrenched, even without explicit exclusionary policies. [Fig.4]
'Sure Start'* Funding per Child by Area Deprivation (England, 2011–2018)
CPAG (2020), Fig. 15.1
This figure illustrates a reduction in early years preventive spending during the period of austerity, with the largest cuts occurring in the most disadvantaged areas. Funding for services such as 'Sure Start'* declined across all areas, with disproportionately greater reductions in more deprived communities, contributing to widening inequalities in early childhood support. (Adapted from Child Poverty Action Group (2020), Figure 15.1. Data from Place-based Longitudinal Data Resource (PLDR).
* 'Sure Start' is a UK government early years program providing integrated health, education, and family support services, particularly in disadvantaged areas (European Commission, 2006).
Drawing on community-based and co-designed research, speakers emphasized that barriers rarely occur in isolation. Instead, families often face an accumulation of obstacles, with socioeconomic hardship, administrative complexity, and service inflexibility intersecting. Evidence from community engagement and third-sector interventions illustrated how:
Importantly, speakers cautioned against interpreting disengagement as disinterest or refusal, noting that such interpretations risk misattributing system failure to individual behavior.
The evidence presented in this section highlights that improving vaccination equity requires intentional redesign of access pathways, informed by an understanding of socioeconomic realities. Participants stressed that effective strategies must:
Key question: Where does mistrust come from?
Evidence presented during the meeting highlighted that trust in vaccination is inseparable from trust in institutions. Speakers consistently cautioned against framing vaccination challenges as issues of individual confidence or misinformation alone, emphasizing instead that mistrust often reflects historical experiences, structural inequities, and perceived institutional failures. In this context, trust is not simply a matter of persuasion, but an outcome shaped by how systems operate, communicate, and engage with communities over time.
A central insight from the briefings was that trust should be understood as a relational and systemic phenomenon, rather than a fixed attribute of individuals or communities. Speakers noted that trust is built—or eroded—through repeated interactions with public institutions, healthcare services, and government authorities. Where systems are experienced as inconsistent, inaccessible, or unresponsive, mistrust can become a rational response rather than a deviation from expected behavior. Importantly, speakers stressed that communities labeled as "hesitant" are often responding to broader institutional signals rather than rejecting vaccination per se.
Evidence presented during the meeting demonstrated that confidence in vaccination does not exist in isolation from the political environment. Speakers highlighted how declining trust in governments, public authorities, and expert institutions can spill over into perceptions of vaccination programs, even when vaccines themselves are not the direct source of concern. This dynamic was described as particularly salient in contexts marked by:
Such conditions can undermine institutional credibility and weaken the social contract between communities and health systems, with vaccination becoming a visible proxy for wider discontent.
Several speakers emphasized that vaccination decisions are embedded within moral economies that shape how information is interpreted and acted upon. Evidence from marginalized and religious communities illustrated that trust is often mediated through:
Crucially, speakers cautioned against assuming that religion or culture constitutes an inherent barrier to vaccination. Instead, mistrust may arise when institutional approaches fail to recognize community diversity, rely on stereotypes, or engage in tokenistic forms of "cultural sensitivity."
Evidence consistently showed that healthcare professionals remain among the most trusted actors in vaccination decision-making. However, speakers noted that this trust is increasingly strained by:
Participants stressed that trust in healthcare professionals cannot indefinitely compensate for systemic shortcomings. Without adequate support, training, and policy alignment, frontline professionals may be placed in an untenable position, expected to rebuild trust without the tools or authority to address underlying system failures.
The evidence presented suggests that restoring and sustaining trust requires institutional change rather than intensified messaging. Speakers emphasized that effective trust-building strategies must:
Participants warned that communication strategies disconnected from these broader considerations risk reinforcing mistrust, particularly among communities that already feel marginalized or overlooked by public institutions.
Key question: What shapes vaccination decision-making in communities?
Evidence presented during the meeting highlighted that vaccination decision-making is shaped not only by access, trust, or information, but by moral economies—the shared values, norms, and social obligations that structure how communities understand responsibility, risk, and authority. Speakers emphasized that vaccination programs themselves operate within moral frameworks, but that these frameworks may conflict with community-based understandings of good parenting, protection, and collective responsibility, particularly in marginalized or tightly networked groups. Crucially, the evidence challenged the frequent tendency to frame religion or culture as intrinsic barriers to vaccination, instead locating under-vaccination within social organization, authority structures, and networked decision-making.
The briefing demonstrated that vaccination is not perceived solely as a biomedical intervention, but as a moral and social act. Routine schedules, for example, implicitly communicate norms about responsible parenting, acceptable risk, and social obligation. Where these institutional norms align with community moral economies, vaccination is reinforced as routine. Where they diverge, trust may be weakened. Speakers highlighted that moral economies are not static. They are shaped by historical experience, political context, and circulating narratives—both formal and informal. In this sense, trust in vaccination reflects not only confidence in vaccines but also confidence in the moral legitimacy of the systems that promote them.
Evidence presented during the meeting cautioned strongly against treating religion as a homogeneous or self-explanatory category in vaccination equity discussions. Speakers noted that public health literature and practice frequently cite "religious beliefs" as a cause of under-vaccination without clearly defining what those beliefs are or how they operate in practice. Importantly, the evidence established that no major religious doctrine explicitly forbids vaccination, and that religious identity alone does not predict vaccination behavior. Instead, mistrust is more often shaped by experiences of exclusion, coercive enforcement, or lack of meaningful engagement with institutions. Framing religion as a barrier was described as analytically limited and potentially counterproductive, as it risks obscuring the structural and relational drivers of inequity.
Vaccination decisions within marginalized or religious communities are often shaped more by gendered and family-based social networks than by formal religious authorities. Speakers emphasized the influential role of peers, siblings, and trusted community members in shaping vaccination norms, particularly among mothers. These findings challenge the assumption that engagement efforts should focus primarily on religious leaders. Instead, decisions are frequently negotiated within everyday social relationships, where shared experiences and perceived norms exert significant influence. Recognizing these dynamics is essential for designing engagement approaches that reflect how decisions are actually made, rather than how institutions assume they are made.
