LTP Priority: Improving Access to Health services: Inclusion Health Groups
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Improving vaccination uptake in Gypsy, Roma and Traveller and other inclusion health groups via the World Health Organization (WHO) Tailoring Immunisation Programmes (TIP) Model.
Major driver of health inequalities in your area of work
The UK vaccination schedule is offered to everyone in the UK free of charge and regardless of residency status. However, there are groups of people who are socially excluded and are less likely to avail of them. This leads to worse health outcomes among some of the most vulnerable population groups, which contributes considerably to health inequalities. This also leads to an increased use of acute services, leading to increased cost for the healthcare system.
Low rates of immunisation are a result of multiple barriers: lack of understanding of the system, such as rights to free primary healthcare and immunisations; communication and language issues; fears based on cultural beliefs; inflexible work arrangements; regularly moving home or moving from a country with fragmented healthcare systems; and low access to immunisation services that meet the needs of the community. Socially excluded people usually experience several of these barriers at once.
Deprivation and inclusion health groups: vulnerable migrants (refugees and asylum seekers), those from the Gypsy, Roma and Traveller communities.
Improving vaccination uptake in Gypsy, Roma and Traveller and other inclusion health groups via the World Health Organization (WHO) Tailoring Immunisation Programmes (TIP) Model.
Several measles outbreaks in the UK in 2017 and 2018 have been linked to importations from Europe, particularly Romania, with initial spread concentrated in the Romanian and other under-vaccinated communities. Many of the people affected were not registered with a GP and did not speak English, so community outreach and engagement, including domiciliary vaccination and community clinics, was a key component of the outbreak response (PHE, 2019).
There is evidence of gradient in vaccine coverage amongst Gypsy, Roma and Traveller communities, as well as multiple other groups – for example, by religious affiliation, and in looked after children and migrants (Wilson, 2018; Gallagher, 2016; Bocquier, 2017; Hermann, 2019; Fournet, 2018).
To meet vaccination targets set out by PHE’s Measles and Rubella elimination strategy, special attention to encourage vaccination uptake in inclusion health groups and other undervaccinated groups will be needed.
Evidence has shown that approaches are most effective when tools and frameworks help support local areas in developing approaches that are tailored to their own populations and context. The World Health Organization (WHO) – Europe developed the guide to tailoring immunisation programmes (TIP) to assist health care professionals, public health authorities and decision-makers in tailoring services to close immunity gaps (WHO, 2013).
The intervention described below is one model, but approaches should be tailored to target populations and settings, in line with WHO TIP or other guidance (see references below).
Example of a tailored intervention
This intervention involves a multi agency partnership across NHS, LA, PHE, Community and Third Sector agencies.
The intervention will first aim to identify the areas of the city in which the target communities reside and determine existing levels of measles, mumps and rubella (MMR) vaccine coverage in this population group. It will offer vaccination to those with incomplete or no MMR vaccination, delivered by GPs to the adult population and by the school vaccination team in schools to children The intervention was developed based on the WHO TIP model and implemented in Greater Manchester where it led to people of the Roma community registering with primary care and being linked into the health screening schedule. Evidence shows the increased protection garnered from one dose of MMR reduces the risk of large scale outbreaks in the community and in large school populations and supports PHE’s Measles and Rubella elimination strategy.
Evidence of hospital admissions and resulting cost to healthcare during a large UK outbreak of measles
SamGhebrehewet; DominicThorrington; SiobhanFarmer; JamesKearney; DeidreBlissett; HughMcLeod; AlexKeenan: The economic cost of measles: Healthcare, public health and societal costs of the 2012–13 outbreak in Merseyside, UK
Evidence of hospitalisation during outbreaks of measles in the UK
R Vivancos, A Keenan, S Farmer, J Atkinson, E Coffey, E Dardamissis, J Dillon, R J Drew, M Fallon, R Huyton, R Jarvis, G Marsh, R Mason, T Shryane, A Stewart, S Ghebrehewet: An ongoing large outbreak of measles in Merseyside, England, January to June 2012. Eurosurveillance, Volume 17, Issue 29, 19/Jul/2012
Evidence of barriers to vaccine uptake in the Roma Community
Jackson C, Bedford H, Cheater FM, Condon L, Emslie C, Ireland L, Kemsley P, Kerr S, Lewis HJ, Mytton J, Overend K, Redsell S, Richardson Z, Shepherd C, Smith L, Dyson L. Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma. BMC Public Health. 2017 Mar 14;17(1):254. doi: 10.1186/s12889-017-4178-y.
Evidence of social deprivation affecting the uptake of MMR vaccination
D. Hungerford, P. Macpherson, S. Son, S. Farmer, S. Ghebrehewet, D. Seddon, R. Vivancos and A. keenan: Effect of socioeconomic deprivation on uptake of measles, mumps and rubella vaccination in Liverpool, UK over 16 years: a longitudinal ecological study. Published online: 06 November 2015.
There is a robust evidence base/guidance supporting locally-designed, multi-faceted/complex community interventions, broadly analogous to the WHO TIPS approach, which informed recommendations in NICE Guidance: related quality statements for evidence-based service provision, and one of the underpinning systematic reviews.
Wilson et al. 2018. Barriers to immunisation among newcomers: A systematic review. Vaccine 36 (2018) 1055–1062.
Gallagher et al. 2016. Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review. BMC Public Health (2016) 16:172. DOI 10.1186/s12889-016-2845-z
Aurélie Bocquier, Jeremy Ward, Jocelyn Raude, Patrick Peretti-Watel and Pierre Verger. 2017. Socioeconomic differences in childhood vaccination in developed countries: a systematic review of quantitative studies, Expert Review of Vaccines, 16:11, 1107-1118, DOI: 10.1080/14760584.2017.1381020
Hermann et al. 2019. Immunization Coverage of Children in Care of the Child Welfare System in High-Income Countries: A Systematic Review. Am J Prev Med 2019;56(2):e55−e63.
Fournet et al. 2018. Under-vaccinated groups in Europe and their beliefs, attitudes and reasons for non-vaccination; two systematic reviews. BMC Public Health (2018) 18:196. DOI 10.1186/s12889-018-5103-8.