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

"Trust can only be achieved through effective healthcare professional and provider engagement, which is reliant on the development and maintenance of links with communities."

Studies find that both Roma and Romanian communities who have migrated to the United Kingdom (UK) have experienced persecution, social exclusion, health inequalities, and discrimination. Such experiences, alongside issues such as cultural and linguistic barriers, can affect vaccination levels among migrant populations like these. As Romanian and Roma communities are at risk of under-vaccination and were affected by measles outbreaks in 2017-18 in the UK, the researchers conducted a qualitative interview study to explore factors contributing to vaccination uptake amongst these communities.

Across the UK cities of Birmingham, Leeds, and Liverpool, the researchers conducted semi-structured interviews with 33 key providers to explore their experience in delivering vaccinations and managing the outbreak response. Following a process of recruitment that took place through an Eastern European women's community group led by a Gypsy, Roma and Traveller (GRT) outreach worker, they also interviewed 9 female Romanian community members (CMs) in one of the cities to explore their vaccination attitudes and behaviours.

Ten main factors were reported to influence vaccination uptake, which are explored in the article under the categories used in the 5As Taxonomy for Determinants of Vaccine Uptake (Access, Affordability, Awareness, Acceptance, and Activation) and illustrated through quotations from the study participants. Sample findings:

• With regard to access: For example, CMs reported language and literacy as major barriers to accessing credible vaccine information and giving informed consent for vaccination. Providers also highlighted communication as a factor affecting their ability to properly explain vaccinations and to promote vaccination. One CM highlighted that those requiring an interpreter may not be aware that GPs are obligated to provide interpreting services.
• With regard to affordability: For example, in the context of other competing demands, vaccination was often not one of the main priorities for community members.
• With regard to awareness: For example, the majority of CMs were not provided with written vaccination in translated forms. Several sought information from family and friends, in addition to healthcare professionals. One CM also discussed having used social media as a source of vaccine information.
• With regard to acceptability: For example, past experiences of vaccinations and health care, in Romania and the UK, affected the decision to access vaccinations and health services amongst some of the CMs. "This highlights the importance of understanding the context of people's lives and how this shapes health decision-making."
• With regard to activation: For example, providers reported that, as compared to sending vaccination reminders to CMs via letter or text message, face-to-face communication was more effective for reaching communities and gaining their trust. In order to promote vaccination, providers suggested that it would be beneficial to involve members of the community as vaccine advocates. It was also felt that there needed to be a more integrated approach, involving different local organisations (e.g., schools, social care providers, local authorities, health visiting and midwifery services, and general practice) in identifying, understanding, and building trust with communities.

In brief, factors related to access and acceptance were reported as the main barriers to vaccination; concerns around vaccination safety and importance appeared to be less dominant contributing factors to vaccination uptake. The CMs who declined vaccination in this study demonstrated vaccine hesitancy; their views were altered through gaining a trusting relationship with healthcare professionals. "Developing trust largely relies on the development of mutual awareness and understanding between providers and community members, and the overcoming of communication barriers."

In conclusion, the researchers recommend that efforts be made to engage with communities, ensure the availability of credible vaccine information, and promote the accessibility of health services and vaccinations. "Better provider-service user relationships are essential to promote not only vaccination but also to reduce inequalities in health service access more broadly."