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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:
- 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.
- Beliefs about the need for vaccination, or about vaccine safety.
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.
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 findings. BMC 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 Roma. BMC 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 providers. J Public Health. 2020;fdaa100.
Funding: This research was funded by the NIHR Health Technology Assessment programme.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.