What have we learnt from measles outbreaks in 3 English cities? A qualitative exploration of factors influencing vaccination uptake in Romanian and Roma Romanian communities

Abstract

Background: Since 2016, large scale measles outbreaks have heavily affected countries across Europe. In England, laboratory confirmed measles cases increased almost four-fold between 2017 and 2018, from 259 to 966 cases. Several of the 2017-18 measles outbreaks in England particularly affected Romanian and Roma Romanian communities, with the first outbreaks in these communities occurring in Birmingham, Leeds and Liverpool. This study explored factors influencing vaccination behaviours amongst Romanian and Roma Romanian communities in these three cities. Methods: Across Birmingham, Leeds and Liverpool, we conducted semi-structured interviews with 33 key providers to explore their experience in delivering vaccinations and managing the outbreak response. We also interviewed 9 Romanian women in one of the cities to explore their vaccination attitudes and behaviours. To categorise factors affecting vaccination we applied the 5As Taxonomy for Determinants of Vaccine Uptake (Access, Affordability, Awareness, Acceptance and Activation) during data analysis. Findings: Factors related to access and acceptance, such as language and literacy, ease of registering with a general practice, and trust in health services, were reported as the main barriers to vaccination amongst the communities. Concerns around vaccination safety and importance were reported but these appeared to be less dominant contributing factors to vaccination uptake. The active decline of vaccinations amongst interviewed community members was linked to distrust in healthcare services, which were partly rooted in negative experiences of healthcare in Romania and the UK. Conclusion: Access and acceptance, dominant barriers to vaccination, can be improved through the building of trust with communities. To establish trust providers must find ways to connect with and develop a greater understanding of the communities they serve. To achieve this, cultural and linguistic barriers need to be addressed. Better provider-service user relationships are crucial to reducing vaccination inequalities and tackling broader disparities in health service access.

Defining the determinants of under-vaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review

“…Specific barriers for European Roma were highlighted, with providers unaware of the difference between Roma and Romanian and lack of access to Romani-speaking interpreters. (36,55) Health professionals reported that the time allocated for vaccination appointments (10-15 minutes) was unrealistic when faced with communication barriers. (55) These barriers were mirrored at the system level in the lack of accessible, tailored or translated information about vaccination, available in different formats, for migrant populations.…”

“…(31,36,65) Fears of being charged for care or asked about immigration status, distrust of HCPs and authorities based on rumours or past experiences of discrimination, difficulties registering with a GP, or being refused care, were also highlighted. (7,31,36,(55)(56)(57)65) These fears were a major barrier to COVID-19 vaccination access in two UK studies of asylum seekers, refugees, and migrants with precarious immigration status, who expressed concern that they would be de-prioritised or excluded from the COVID-19 vaccine roll-out because of their status. (7,56) Migrants (n=10) interviewed after government announcements to widen COVID-19 vaccine access to undocumented migrants also remained unaware that they could be accessed free of charge and without immigration checks.…”

“…Distrust of the healthcare system and fear of being questioned about one's legal status was reported as a barrier both to accessing, and accepting, routine and COVID-19 vaccination. (7,31,52,55,56,65) Interestingly, Ukrainian migrants in Poland expressed distrust of their home country's vaccination policy, public servants, and medical system, but this made them more accepting of vaccination in Poland, where they felt the quality of vaccines and the healthcare system were higher. (57) v.…”

Responding to measles outbreaks in underserved Roma and Romanian populations in England: the critical role of community understanding and engagement

“…Interviews for this study were limited to providers; however, in preceding studies, we have included Romanian and Roma community members to explore factors affecting vaccination uptake [27,30].…”

“…This study was undertaken in parallel with research we conducted with Romanian and Roma community members in Birmingham, Leeds and Liverpool to explore factors affecting vaccination at the time of the 2017/18 measles outbreaks. We found that factors related to access and acceptance, such as language and literacy barriers, ease of registering with a general practice (GP) and trust in health services, were the main barriers to vaccination amongst the communities [30]. The largest contributors to under-vaccination in the communities were due to access barriers, linked to social determinants, rather than community members' actively refusing vaccination.…”