Responding to Measles Outbreaks in Underserved Roma and Romanian Populations in England: The Critical Role of Community Understanding and Engagement

"To increase uptake in under-vaccinated communities, local knowledge and engagement are vital to build trust and relationships. Local partners must work proactively to identify, understand and build connections with communities."

Vaccination uptake has been reported as lower in Roma communities compared to non-Roma communities across Europe, and, in 2017-18, several measles outbreaks occurred in England that specifically affected Romanian and Romanian Roma communities. An earlier study found that factors related to access and acceptance, such as language and literacy barriers, ease of registering with a general practice (GP) and trust in health services, were the main barriers to vaccination amongst the communities (see Related Summaries, below). A follow-up to that research, this qualitative interview study examined the effectiveness of outbreak responses and efforts to promote vaccination uptake amongst these underserved communities in three English cities.

Semi-structured in-depth interviews were conducted between June 2018 and January 2019 with 33 providers involved in vaccination delivery and outbreak management in Birmingham, Leeds, and Liverpool.

Factors that influenced the effectiveness of responses in reaching underserved Romanian and Roma communities were categorised into five themes:

1. The ability to identify the communities - "With vaccination coverage data only available at local authority, clinical commissioning group (CCG) and GP level, it was challenging for providers to identify 'pockets' of lower uptake within the population....Several providers reported being aware of the existence of unmet health needs amongst Romanian and Roma communities ahead of the outbreaks but felt unlistened to and hence restricted in their abilities to address inequalities within the communities." The researchers suggest that one resource that could be used by providers to bring a range of existing datasets together to identify under-vaccinated communities is the Strategic Health Asset Planning and Evaluation (SHAPE) Atlas. SHAPE allows users to visualise layered maps of multiple datasets (e.g., location of healthcare facilities) and indicators (e.g., deprivation, ethnicity, age profile) for their local area.
2. Provider knowledge and understanding of the communities - Without having context to the history of discrimination and persecution towards Roma, GPs' poor understanding of these communities and factors affecting vaccination impeded effective strategies to manage the outbreaks.
3. The coordination of response efforts and partnership building - Providers reported challenges in identifying responder roles and responsibilities, promptly coordinating efforts, and communicating with hospitals and officials.
4. Links to communities and approaches to community engagement - Providers reported outreach approaches, such as door-to-door knocking, using mobile vaccination vans and offering vaccinations in community centres, as effective in increasing vaccination uptake. Key to the effectiveness of these strategies was being able to take advantage of preexisting links and established trust with the communities. Frontline healthcare providers made efforts to engage with Romanian communities by, for example, employing Romanian speaking receptionists, sending letters and SMS (text) messages in Romanian, and holding additional clinics. Providers in the three cities highlighted that encouraging communities to access GPs was not always effective, and that the system of booking future appointments was often ineffective. On the other hand, having strong links or contacts working directly with local communities (e.g., children's centre managers) was reported as essential. Overall, the most effective approaches to outbreak management were multi-faceted and relied on insight into the communities.
5. Resource constraints - For example, although face-to-face communication was seen as key to successful engagement, participants reported difficulties in sourcing and funding translators and interpreters. In one of the cities, leaflets had been developed in Romanian but the interpreters stated that the wrong dialect was used in these. In community and GP settings, several participants discussed using hand gestures to communicate or using Google translate during consultations. This raised concerns that messages would be lost in translation. (One recommendation that emerged from the interviews was to try and share more resources, such as translators and interpreters.) Also, providers felt their ability to engage with and improve uptake in underserved communities was exacerbated by an immunisation target payment system focused solely on outcomes and not process; National Health Service (NHS) England is reportedly reviewing these policies, with a focus on trying to reduce inequalities in vaccination.

In short, the research found that, without prior understanding and linkage with Romanian and Roma communities, it was difficult for providers to identify and access these communities, who may not trust providers. Effective partnership building and community engagement were found to be crucial ways of addressing these barriers.

The researchers suggest that findings from the study may be applicable to other underserved communities, particularly those not accessing the GP or the school system, those who may be unfamiliar with vaccination delivery, and those who experience language and literacy barriers.