Evidence
In this video, a narrator explains the background and results of the study, and animations are used to illustrate the narrative.

[Text on screen] How can Gypsies, Roma, and Travellers get the immunisations they want?

[Narrator] Immunisations are provided for many different people within our society, to help protect against diseases that are passed from person to person. Older people - to stop them getting flu, pregnant mums - to stop their babies getting whooping cough, and children - to protect them from nasty bugs. However not all people get the immunisations they need to protect them.
There is some evidence that more people in Gypsy, Traveller and Roma communities are not fully immunised compared with the general population. We undertook research to find out why this is.
Our study was carried out in four parts of the UK, including interviews with 174 Gypsies, Roma and Traveller people. We also talked to 39 people who provide health services for Gypsies, Roma and Travellers, including midwives, health visitors, doctors and those who plan health services. Finally we held workshops with 25 health providers and 51 Travellers to come up with some ideas on how to help people get the immunisations they want. What did we find?
Research has shown that the main reasons people don't have immunisations are that they don't accept that all vaccines are helpful, and that they find it hard to access some or all vaccines. And it is just the same for Gypsies, Roma and Traveller people. Some didn't know that pregnant women can have an immunisation for whooping cough. Some didn't think teenage girls needed the HPV vaccine before they were married. But ideas are changing in Gypsy, Roma and Traveller communities between the older and younger generations. And parents are now more likely to ask a health professional for advice about immunisation and use a computer to look up information.
Most people we interviewed believe immunisations are the best way of protecting themselves and their children from diseases. Sometimes people found it hard to get the immunisations because they didn't speak English, like many Roma people. Or they have difficulties in reading. They didn't have a health professional they could trust to ask for advice. Or they found it difficult to register or make an appointment at the doctor's.
Like everyone else, Gypsies, Roma and Travellers want to protect themselves and their children from infectious diseases. Here are some simple ways to help them: making sure health professionals know about Gypsy, Roma and Traveller culture; recording in the health records that people are Gypsy, Roma and Travellers, and making sure they are not missing out on immunisations; making sure there is a receptionist at the doctors who understands about Gypsy, Roma and Traveller culture, and can provide support with using the service; offering different ways to get appointments and advice from the doctor or nurse; providing a special health visitor for Gypsy, Roma and Traveller families.
Visit bit.ly/GTRimmunisation for the full research study.
[Text on screen] This project was funded by the National Institute for Health Research Technology Assessment Programme (project number 12/17/05).The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Health Technology Assessment programme, NIHR, NHS, or the Department of Health.
Logo: Swansea University, Prifysgol Abertawe
Animation by Savage & Gray Design, savageandgray.co.uk
Music: http://www.bensound.com

Better access to healthcare for Gypsy, Roma and Traveller communities is key to increasing vaccination rates: research makes five recommendations

Better access to healthcare services is the most important step in improving vaccination rates for people in Gypsy, Roma and Traveller communities. New research suggests that easier access is more important than addressing beliefs about vaccine safety or the need for vaccination.

Researchers set up a series of workshops for healthcare providers and representatives of Gypsy, Roma and Traveller communities. Together, participants produced a list of five proposals to improve vaccination rates. The proposals focused on access to services; the most important was training in cultural competence for front-line staff in general practice.

The other proposals were noting Gypsy, Roma and Traveller ethnicity on healthcare records, having a named person in the GP practice for communities to approach, flexible appointment systems and funding for specialist health visitors.

These findings are important at a time when the NHS is charged with vaccinating the adult population against coronavirus. People from Gypsy, Roma and Traveller communities in the UK are thought to be less likely to have immunisations than other people so understanding how best to improve uptake is crucial.

The new research concluded that the proposals would work best if introduced as a combined package. They might also improve vaccination rates in other communities. However, the proposed ideas have not been tested in a formal trial to see if they increase vaccination rates in practice.

What’s the issue?

There is little information about uptake of vaccinations among Gypsy, Roma and Traveller communities in the UK. This may be because these ethnic groups are not routinely recorded on healthcare records. However, uptake is thought to be lower than average. In 2010, despite widespread availability of vaccination, there were outbreaks of measles among Gypsy and Traveller communities. This prompted the Department of Health to urge local health services to offer vaccinations to these communities.

Previous work to understand the low uptake of immunisation has identified two main barriers:

  1. Access to healthcare (including immunisation) because of issues such as low literacy, a lack of trusted relationships with healthcare providers and irregular school attendance increase the difficulties. Lack of a fixed postal address can make it difficult to register with a GP, and also means that immunisation needs to be offered promptly, before people have moved on.
  2. Beliefs about the need for vaccination, or about vaccine safety.

What’s new?

At an earlier stage of the project, researchers held interviews with 174 representatives from Gypsy, Roma and Traveller communities and 39 healthcare providers. Interviewees came up with 15 proposals to overcome barriers to vaccination. This study aimed to prioritise the proposals, with both groups working together to produce a shortlist of the five they thought likely to be helpful.

Five workshops were carried out in Bristol, York, Glasgow and London. They included healthcare providers and representatives of various Gypsy, Roma and Traveller communities: Eastern European Roma, English Gypsy, Irish Traveller, and Scottish Show people. All were in housing or on authorised sites; the research did not include people from roadside or unauthorised camps.

The study included 51 Gypsy, Roma and Traveller representatives and 25 healthcare providers. The communities’ representatives mainly prioritised interventions that improved access to services. Some healthcare providers gave higher priority to interventions (such as targeted information campaigns) aimed at changing beliefs about vaccinations. After discussion, the prioritised interventions mainly addressed access to acceptable services.

The workshops co-produced a list of the five most feasible and acceptable proposals.

Ranked in order of importance, the proposals were:

  • Cultural competence training for GPs, practice nurses, health visitors, midwives, specialist health workers and receptionists. This should challenge negative stereotypes, and cover the communities’ views on vaccination (positive and negative).
  • Noting the ethnic group in healthcare records. Electronic health records held by GPs and immunisation datasets should be updated to include this information; new patient registration forms should collect it.
  • A named frontline person in the GP practice (potentially a receptionist or practice administrator) should be able to provide respectful and supportive services to people from Gypsy, Roma and Traveller communities. This may include support with literacy or language issues.
  • Flexible systems for booking appointments for vaccinations, which should use SMS text to contact people directly, as well as letters (which may be delayed if they go to shared mailboxes). Appointments within one or two days of booking were better than appointments two weeks in advance, and some communities wanted access outside of normal working hours.
  • Funding for health visitors specialising in Gypsy, Roma and Traveller health should be protected, as these outreach services were highly valued by the communities.

Why is this important?

The workshops were informal and interactive, and participants said it was the first opportunity they had had to speak with each other. There were differences in emphasis between the groups.

Gypsy, Roma and Traveller communities sought trusted relationships with healthcare providers who understand and respect their communities. Proposals which could help build these relationships may therefore have more impact on immunisation rates than, for example, the targeted information campaigns suggested by some healthcare providers. The researchers say the priorities agreed after discussion between the groups may be more acceptable than interventions proposed by healthcare providers alone.

These findings are important at a time when the NHS not only needs to maintain standard immunisations, but to rapidly roll out the Covid-19 vaccination campaign across the entire adult population. This must include Gypsy, Roma and Traveller communities.

What’s next?

Some areas have already begun to record Gypsy, Roma and Traveller ethnicities in healthcare records, in line with the proposal. However, there is no national push to do so. The researchers say funding for specialist services has been withdrawn in some areas and may be difficult to continue at a time of high demand across the health service. Likewise, cultural competence training requires time and money to implement. Text messaging for appointments is already used by many GP services and could be rolled out more widely.

The researchers say that the co-production methods used could be helpful in working with other communities with low uptake of immunisations. However, the suggested interventions need to be tested to see whether they increase vaccination rates in practice – and how much they cost. It is also unknown whether people who live in Gypsy, Roma and Traveller communities on the roadside or in unauthorised camps would agree with, and be helped by, the proposals.

You may be interested to read

The full paper: Dyson L, and others. Identifying interventions with Gypsies, Roma and Travellers to promote immunisation uptake: methodological approach and findingsBMC Public Health 2020; 20:1574.

Background to the need to improve immunisation in these communities: Jackson C, and others. UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study. Health Technol Assess 2016;20:72.

Initial work on this project: Jackson C, and others. Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers, and RomaBMC Public Health 2017;17:254.

Further related reading: Mytton J, and others. Improving immunisation uptake rates among Gypsies, Roma and Travellers: a qualitative study of the views of service providersJ Public Health. 2020;fdaa100.

The Friends, Families and Travellers website

Funding

This research was funded by the NIHR Health Technology Assessment programme.

Commentaries

Study author

We knew from the first part of the study that ideas about immunisation in these communities are not that different from other communities, or the general population. That’s not the problem.

It is the issue of access, and all the interventions that came out of this research are about making services more acceptable and accessible. The role of GP practices and front-line workers in building trust with communities is really important. Information provided outside the context of a trusted relationship doesn’t do a lot.  It’s about involving people in organisations, and forming good relationships between local health services and Gypsy, Roma and Traveller communities. There are places that are happening. There are ways of doing it well.

Louise Condon, Professor of Nursing, College of Human and Health Sciences, Swansea University 

Friends, Families and Travellers 

The paper sets out some simple, practical steps services can take to improve immunisation uptake in Gypsy, Roma and Traveller communities. We hope this will improve practice.

There are still gaps in our knowledge. The paper focuses on people living on Traveller sites or in bricks and mortar housing. But those who live on roadside camps have the greatest difficulties in accessing primary care and therefore immunisations (due to lack of continuity of care when travelling and to wrongfully refused registrations).

Accessible information for people with low levels of literacy or English language was not a key intervention. At Friends Families and Travellers, around two in five (40%) of our service users have low or no literacy. We know from our casework that services which do not recognise and respond to this often exclude affected individuals. The paper states that written sheets were used in the workshops, so we can assume that level of literacy and confidence in reading and writing may have been a barrier to taking part.

Two focus groups used a translator so we can assume that language was a barrier to taking part and might also be a barrier to accessing healthcare. It is not clear how language (which would only affect some people from Roma communities) and literacy (which would only affect some people from Gypsy and Traveller communities) has been accounted for. Gypsy, Roma and Traveller communities are diverse and have different needs; this is often not understood by the general public, researchers or policymakers.

Sarah Sweeney, Health Policy and Research Lead, Friends, Families and Travellers, a national charity working on behalf of Gypsy, Roma and Traveller communities.  

Conflicts of Interest

None declared.