UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study

Understanding the health system barriers and enablers to childhood MMR and HPV vaccination among disadvantaged, minority or underserved populations in middle- and high-income countries: a systematic review

BACKGROUND

Child vaccinations are among the most effective public health interventions. However, wide gaps in child vaccination remain among different groups with uptake in most minorities or ethnic communities in Europe substantially lower compared to the general population. A systematic review was conducted to understand health system barriers and enablers to measles, mumps and rubella (MMR) and human papilloma virus (HPV) child vaccination among disadvantaged, minority populations in middle- and high-income countries.

METHODS

We searched Medline, Cochrane, CINAHL, ProQuest and EMBASE for articles published from 2010 to 2021. Following title and abstract screening, full texts were assessed for relevance. Study quality was appraised using Critical Appraisal Skills Program checklists. Data extraction and analysis were performed. Health system barriers and enablers to vaccination were mapped to the World Health Organization health system building blocks.

RESULTS

A total of 1658 search results were identified from five databases and 24 from reference lists. After removing duplicates, 1556 titles were screened and 496 were eligible. Eighty-six full texts were assessed for eligibility, 28 articles met all inclusion criteria. Factors that affected MMR and HPV vaccination among disadvantaged populations included service delivery (limited time, geographic distance, lack of culturally appropriate translated materials, difficulties navigating healthcare system), healthcare workforce (language and poor communication skills), financial costs and feelings of discrimination.

CONCLUSION

Policymakers must consider health system barriers to vaccination faced by disadvantaged, minority populations while recognizing specific cultural contexts of each population. To ensure maximum policy impact, approaches to encourage vaccinations should be tailored to the unique population's needs. A one-size-fits-all approach is not effective.

Mitigating Vaccine Hesitancy and Building Trust to Prevent Future Measles Outbreaks in England

Measles, a highly infectious respiratory viral infection associated with severe morbidity and mortality, is preventable when coverage with the highly effective measles, mumps and rubella vaccine (MMR) is ≥95%. Vaccine hesitancy is responsible for measles outbreaks in countries where measles had previously been eliminated, including in England, and is one of the ten threats to global public health identified by the World Health Organization (WHO). Official administrative 2012-2021 data on measles incidence and MMR coverage in England were reviewed alongside a scoping literature review on factors associated with MMR uptake in England. Whilst measles incidence has reduced significantly since 2012, sporadic measles outbreaks in England have occurred with geographic disparities and variations in MMR coverage. Over the last decade, MMR uptake has fallen across all regions with no area currently reaching the WHO target of 95% coverage of both doses of MMR necessary for herd immunity. Factors associated with MMR coverage overlap with the 3C (convenience, complacency and confidence) model of vaccine hesitancy. The COVID-19 pandemic has reinforced pre-existing vaccine hesitancy. Increasing MMR uptake by reducing vaccine hesitancy requires allocated funding for area-based and targeted domiciliary and community-specific immunisation services and interventions, public health catch-up campaigns and web-based decision aid tools.

Exploring key informants' perceptions of Covid-19 vaccine hesitancy in a disadvantaged urban community in Ireland: Emergence of a '4Cs' model

AIM

The aim of this study was to explore key informants' views on and experiences with Covid-19 vaccine hesitancy in a Dublin community with a high concentration of economic and social disadvantage and to identify feasible, community-centred solutions for improving vaccination acceptance and uptake.

METHODS

Qualitative, semi-structured interviews were carried out at a local community-centre and a central hair salon. Twelve key informants from the target community were selected based on their professional experience with vulnerable population groups: the unemployed, adults in recovery from addiction, the elderly, and Irish Travellers. Inductive thematic framework analysis was conducted to identify emergent themes and sub-themes.

RESULTS

Drivers of vaccine hesitancy identified by key informants largely fell under the WHO '3Cs' model of hesitancy: lack of confidence in the vaccine and its providers, complacency towards the health risks of Covid-19, and inconvenient access conditions. Covid-19 Communications emerged as a fourth 'C' whereby unclear and negative messages, confusing public health measures, and unmet expectations of the vaccine's effectiveness exacerbated anti-authority sentiments and vaccine scepticism during the pandemic. Community-specific solutions involve the provision of accurate and accessible information, collaborating with community-based organizations to build trust in the vaccine through relationship building and ongoing dialogue, and ensuring acceptable access conditions.

CONCLUSIONS

The proposed Confidence, Complacency, Convenience, Covid-19 Communications ('4Cs') model provides a tool for considering vaccine hesitancy in disadvantaged urban communities reacting to the rapid development and distribution of a novel vaccine. The model and in-depth key informants' perspectives can be used to compliment equitable vaccination efforts currently underway by public health agencies and non-governmental organizations.

Public involvement in participatory research: the experiences of peer interviewers from Roma, Gypsy and Traveller communities

BACKGROUND

A vital component of research is patient and public involvement (PPI). The challenges of PPI increase when conducting cross-cultural research into sensitive subjects with marginalised ethnic minority groups.

AIM

To present the authors' reflections on conducting peer interviews with members of Roma, Gypsy and Traveller communities.

DISCUSSION

The authors provide examples of reflections on collecting data from a participatory research project that explored Gypsies, Roma and Travellers' experiences of cancer in their communities. They derived the reflections from audio-recorded, post-interview debriefs with co-researchers from the same ethnic backgrounds as interviewees ('peer researchers'). The main challenges for the peer researchers were cultural, linguistic and pragmatic, all fundamentally related to exploring a sensitive health topic through the lens of ethnicity.

CONCLUSION

Peer researchers recognised their role in building bridges between participants and the research team. They did this by establishing a relationship of trust, minimising distress, representing the views of their communities and obtaining data to meet the aims of the project. Peer researchers perform multiple roles to assist in cross-cultural data collection in participatory research.

IMPLICATIONS FOR PRACTICE

This article highlights underexplored aspects of peer researchers' work that have implications for the planning and conduct of cross-cultural research with marginalised groups.

Predicting cervical screening and HPV vaccination attendance of Roma women in Hungary: community nurse contribution is key

BACKGROUND

HPV screening/vaccination has been observed lower for ethic minorities. Understanding factors that predict and can improve attendance is therefore key. Hence, the aim was to identify causes, especially concerning the quality of the patient-provider relationship, that predict past HPV screening and vaccination turnout of Roma women in Hungary.

METHODS

Cross-sectional research design with self-developed, culturally sensitive questionnaire. A final, female Roma sample of 368 participants was randomly selected from census register. Community nurses contacted participants and distributed surveys. Surveys were mailed-in by participants. Bivariate logistic regression was used to predict former participation in HPV screening/vaccination.

RESULTS

Of the total sample, 17.4% of women attended at least one cervical screening and HPV vaccination in the past. Bad screening experience was positively associated with racially unfair behaviors of physicians. The odds of past attendance were 4.5 times greater if 'no negative earlier experience' occurred, 3.3 times likelier if community nurse performed screening/immunization and 1.6 times more probable if respondent felt 'no shame'. Evaluating the screening/vaccination process painful, being only financially motivated and attendance involving a lot of travel decreased the odds of 'no show' by 50%, 40% and 41%, respectively.

CONCLUSIONS

When considering the ratio of past cervical screening attendance, we conclude that our female Roma sample did not behave differently from the general population. We saw no evidence that racial mistreatment made any contribution to explaining cervical screening participation. Past positive screening experience and the quality of patient-provider relationship increased the odds of participation the most. Cancer of friends, pain, financial motivation and travel distance decreased odds of participation to a lesser extent. In order to improve future screening and immunization, community nurses should play more central and advanced role in the organization and implementation of such services specifically targeting Roma populations.

Improving immunization uptake rates among Gypsies, Roma and Travellers: a qualitative study of the views of service providers

BACKGROUND

Gypsies, Roma and Travellers are at risk of low uptake of routine immunizations. Interventions to improve uptake in these communities are seldom evaluated. As part of a qualitative study exploring barriers and facilitators to immunization uptake in Travellers, we report service provider (SP) perspectives.

METHODS

We interviewed immunization SPs working with six Traveller communities across four UK cities. Participants included frontline staff and those with strategic or commissioning roles. Semi-structured interviews explored perceived attitudes of Travellers to vaccinations, local service delivery, and opportunities and challenges to improving uptake. Audio-recordings were transcribed, analyzed thematically and mapped to a socio-ecological model of health.

RESULTS

39 SPs participated. Four overarching themes were identified: building trusting relationships between SPs and Travellers; facilitating attendance at appointments; improving record keeping and monitoring and responding to local and national policy change. Travellers were perceived as largely supportive of immunizations, though system and organizational processes were recognized barriers to accessing services.

CONCLUSIONS

Findings were broadly consistent across Traveller groups and settings. The barriers identified could often be addressed within existing infrastructure, though require system or policy change. Development of a culturally competent system appears important to enable equity in access to immunizations for Travellers.

Knowledge and experience of cancer prevention and screening among Gypsies, Roma and Travellers: a participatory qualitative study

Background

The incidence of cancer is increasing worldwide, which has led to greater public health focus on primary prevention. Ethnic minorities have lower awareness of cancer risk factors and services, and are at greater risk of cancer mortality. While Gypsies, Roma and Travellers have poor health outcomes even in comparison with other ethnic minorities, little is known about how they view and enact primary prevention. This study takes a participatory approach to explore knowledge and experience of cancer prevention and screening in these communities.

Methods

Peer researchers conducted interviews (n = 37) and a focus group (n = 4) with a purposive sample of community members in Wales and South-West England. Participants self-identified as Roma (from Slovakia and Romania) or as Gypsies, Travellers or Showpeople (here described as Gypsy/Travellers). A third of the sample were Roma, and a quarter male, with ages ranging from 18 to 77 years. Data were collected from October 2018 to March 2019.

Results

Women and men knew that lifestyle factors, such as healthy diet, stopping smoking, drinking less alcohol and using sun protection, contribute to cancer risk reduction. However, there was a widespread lack of confidence in the effectiveness of these measures, particularly in relation to smoking. Traditional cultural beliefs were shared by Roma and Gypsy/Travellers, but did not necessarily affect the behaviour of individuals. Most women participated in cervical and breast screening but few Gypsy/Traveller men would engage with bowel screening, which conflicted with community ideals of stoical masculinity. Roma participants described language barriers to screening, with confusion about differences in timing and eligibility between the UK and Slovakian programmes; this led some to access screening abroad.

Conclusion

This study provides new knowledge about how Gypsies, Roma and Travellers keep healthy and prevent disease, giving insights into similarities and differences between ages, sexes and communities. These culturally distinct and high-need ethnic minorities have specific needs in relation to cancer prevention and screening, which merit targeted and acceptable health promotion to reduce health inequalities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10390-y.

Repurposing drug molecules for new pulmonary therapeutic interventions

Drug repurposing with novel strategies has substantially contributed to the identification and analysis of new molecules for better pulmonary intervention. This review would offer insights into the drug repurposing for effective pulmonary therapy. The review begins by explaining the relevant background knowledge of drug repurposing, the need for drug repurposing, and their potential advantages in treating pulmonary diseases. This article takes into account clinical trial problems, drug delivery challenges, regulatory issues, and human ergonomics along with chemistry manufacturing and control strategies for effective pulmonary drug repurposing. This article elaborates on pulmonary drug repurposing with help of strengths, weaknesses, opportunities, and threat analysis. In brief, this article is the first inclusive account of drug repurposing for better pulmonary therapy. Graphical abstract.

Identifying interventions with Gypsies, Roma and Travellers to promote immunisation uptake: methodological approach and findings

BACKGROUND

In the UK, Gypsy, Roma and Traveller (GRT) communities are generally considered to be at risk of low or variable immunisation uptake. Many strategies to increase uptake for the general population are relevant for GRT communities, however additional approaches may also be required, and importantly one cannot assume that "one size fits all". Robust methods are needed to identify content and methods of delivery that are likely to be acceptable, feasible, effective and cost effective. In this paper, we describe the approach taken to identify potential interventions to increase uptake of immunisations in six GRT communities in four UK cities; and present the list of prioritised interventions that emerged.

METHODS

This work was conducted in three stages: (1) a modified intervention mapping process to identify ideas for potential interventions; (2) a two-step prioritisation activity at workshops with 51 GRTs and 25 Service Providers to agree a prioritised list of potentially feasible and acceptable interventions for each community; (3) cross-community synthesis to produce a final list of interventions. The theoretical framework underpinning the study was the Social Ecological Model.

RESULTS

Five priority interventions were agreed across communities and Service Providers to improve the uptake of immunisation amongst GRTs who are housed or settled on an authorised site. These interventions are all at the Institutional (e.g. cultural competence training) and Policy (e.g. protected funding) levels of the Social Ecological Model.

CONCLUSIONS

The "upstream" nature of the five interventions reinforces the key role of GP practices, frontline workers and wider NHS systems on improving immunisation uptake. All five interventions have potentially broader applicability than GRTs. We believe that their impact would be enhanced if delivered as a combined package. The robust intervention development and co-production methods described could usefully be applied to other communities where poor uptake of immunisation is a concern.

STUDY REGISTRATION

Current Controlled Trials ISRCTN20019630, Date of registration 01-08-2013, Prospectively registered.

Supporting the provision of pharmacy medication reviews to marginalised (medically underserved) groups: a before/after questionnaire study investigating the impact of a patient-professional co-produced digital educational intervention

OBJECTIVES

People who are marginalised (medically underserved) experience significant health disparities and their voices are often 'seldom heard'. Interventions to improve professional awareness and engagement with these groups are urgently needed. This study uses a co-production approach to develop an online digital educational intervention in order to improve pharmacy staffs' intention to offer a community pharmacy medication review service to medically underserved groups.

DESIGN

Before/after (3 months) self-completion online questionnaire.

SETTING

Community pharmacies in the Nottinghamshire (England) geographical area.

PARTICIPANTS

Community pharmacy staff.

INTERVENTION

Online digital educational intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was 'behaviour change intention' using a validated 12-item survey measure. The secondary outcome measure was pharmacist self-reported recruitment of underserved groups to the medication review service.

RESULTS

All pharmacies in the Nottinghamshire area (n=237) were approached in June 2017 and responses were received from 149 staff (from 122 pharmacies). At 3 months (after completing the baseline questionnaire), 96 participants (from 80 pharmacies) completed a follow-up questionnaire, of which two-thirds (n=62) reported completing the e-learning. A before/after comparison analysis found an improving trend in all the five constructs of behaviour change intention (intention, social influence, beliefs about capabilities, moral norms and beliefs about consequences), with a significant increase in mean score of participants' 'beliefs about capabilities' (0.44; 95% CI 0.11 to 0.76, p=0.009). In the short-term, no significant change was detected in the number of patients being offered and the patient completing a medication review.

CONCLUSIONS

Although increases in the numbers of patients being offered a medication review was not detected, the intervention has the potential to significantly improve pharmacy professionals' 'beliefs about capabilities' in the short-term. Wider organisational and policy barriers to engagement with marginasied groups may need to be addressed. Future research should focus on the interplay between digital learning and practice to better identify and understand effective practice change pathways.

'I don't think anybody explained to me how it works': qualitative study exploring vaccination and primary health service access and uptake amongst Polish and Romanian communities in England

OBJECTIVES

This study explored vaccination attitudes and behaviours among Polish and Romanian communities, and related access to primary healthcare services.

DESIGN

A qualitative study using in-depth semistructured interviews with Polish and Romanian community members (CMs) and healthcare workers (HCWs) involved in vaccination in areas with large Polish and Romanian communities. CMs discussed their vaccination attitudes and their experiences of accessing vaccinations in England. HCWs shared their experiences in vaccinating Polish and Romanian communities.

SETTING

Recruitment focused on three geographical areas in England with large Polish and Romanian populations (in London, Lincolnshire and Berkshire).

PARTICIPANTS

20 Polish and 10 Romanian CMs, and 20 HCWs. Most CMs were mothers or pregnant women and were recruited from London or Lincolnshire. HCWs included practice nurses, health visitors and school nurses recruited from the targeted geographical areas.

RESULTS

Although most CMs reported vaccinating according to the UK schedule, obstacles to vaccination were highlighted. CMs experienced difficulties navigating and trusting the English primary healthcare system, and challenges in accessing credible vaccination information in Polish and Romanian. CM vaccination expectations, largely built on knowledge and experiences from Poland and Romania, were often unmet. This was driven by differences in vaccination scheduling and service provision in England, such as nurses delivering vaccines instead of doctors. CMs reported lower acceptance of the influenza vaccine, largely due to perceptions around the importance and efficacy of this vaccine. HCWs reported challenges translating and understanding vaccination histories, overcoming verbal communication barriers and ensuring vaccination schedule completeness among families travelling between England and Poland or Romania.

CONCLUSIONS

This study identified vaccination uptake and delivery issues and recommendations for improvement. HCWs should discuss health service expectations, highlight differences in vaccination scheduling and delivery between countries, and promote greater understanding of the English primary healthcare system in order to encourage vaccination in these communities.

Engaging Gypsy, Roma, and Traveller Communities in Research: Maximizing Opportunities and Overcoming Challenges

Gypsy, Roma, and Traveller people are marginalized worldwide and experience severe health inequalities, even in comparison to other ethnic minority groups. While diverse and hard to categorize, these communities are highly cohesive and members have a strong sense of identity as a group apart from the majority population. Researchers commonly experience challenges in accessing, recruiting, and retaining research participants from these communities, linked to their outsider status, insular nature, and history of discrimination. In this article, the challenges and the opportunities of engaging Gypsies, Roma, and Travellers in a multicenter qualitative research project are discussed. The management of public involvement and community engagement in this U.K.-based project provides insights into conducting research effectively with ethnically and linguistically diverse communities, often considered to be "hard to reach."

HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe

Europe is increasingly described as the region in the world with the least confidence in vaccination, and particularly in the safety of vaccines. The aim of this systematic literature review was to gather and summarise all peer-reviewed and grey literature published about determinants of Human Papillomavirus (HPV) vaccine hesitancy in Europe. Ten thematic categories were identified across the 103 articles which were included in the review. Participants from European studies most commonly reported issues with the quantity and quality of information available about HPV vaccination; followed by concerns about potential side effects of the vaccine; and mistrust of health authorities, healthcare workers, and new vaccines. Comparative analyses indicated that confidence determinants differed by country and population groups. This evidence supports the need to develop context-specific interventions to improve confidence in HPV vaccination and design community engagement strategies aiming to build public trust.

Health needs of Gypsy Travellers

Gypsy Travellers have the poorest health of any ethnic group in the population; they also have an inverse relationship between their health needs and access to healthcare services. This article aims to explain the reasons for such stark health inequality, to identify the specific health needs of Gypsy Travellers, and to describe the role of the GP in meeting those needs.

Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma

BACKGROUND

Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services including immunisation. To improve immunisation rates, it is necessary to understand what helps and hinders individuals in these communities in taking up immunisations. This study had two aims. 1. Investigate the views of Travellers in the UK on the barriers and facilitators to acceptability and uptake of immunisations and explore their ideas for improving immunisation uptake; 2. Examine whether and how these responses vary across and within communities, and for different vaccines (childhood and adult).

METHODS

This was a qualitative, cross-sectional interview study informed by the Social Ecological Model. Semi-structured interviews were conducted with 174 Travellers from six communities: Romanian Roma, English Gypsy/Irish Travellers (Bristol), English Gypsy (York), Romanian/Slovakian Roma, Scottish Show people (Glasgow) and Irish Traveller (London). The focus was childhood and selected adult vaccines. Data were analysed using the Framework approach.

RESULTS

Common accounts of barriers and facilitators were identified across all six Traveller communities, similar to those documented for the general population. All Roma communities experienced additional barriers of language and being in a new country. Men and women described similar barriers and facilitators although women spoke more of discrimination and low literacy. There was broad acceptance of childhood and adult immunisation across and within communities, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough and described barriers to booking and attending immunisation. Cultural concerns about antenatal vaccines and HPV vaccination were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified as barriers across different communities. Trustful relationships with health professionals were important and continuity of care valued.

CONCLUSIONS

The experience of many Travellers in this study, and the context through which they make health decisions, is changing. This large study identified key issues that should be considered when taking action to improve uptake of immunisations in Traveller families and reduce the persistent inequalities in coverage.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20019630 .