Barriers and facilitators to immunisation uptake in Traveller communities:uptake in Traveller communities: 

the UNITING study

Dr Susan Kerr, Dr Carol Emslie, Dr Lana IrelandGlasgow Caledonian UniversityGlasgow Caledonian University

&Dr Cath Jackson (PI)( )University of York

(on behalf of the UNITING project team)

Background/Rationaleg• Gypsy/Travellers generally experience poorer health and have 

a shorter life expectancy than the wider populationa shorter life expectancy than the wider population

• Despite greater health need, low uptake of health services, including preventative health care

• Recurring outbreaks of vaccine• Recurring outbreaks of vaccine preventable diseases in Traveller communities suggests immunisation gguptake is low

• Factors influencing uptake need to be understood if effective interventions are to be developed

Aims of the UNITING studyAims of the UNITING study

1. To investigate barriers and facilitators to acceptability and t k f i i ti

Childhood immunisation 

uptake of immunisations among Gypsy/Traveller communities

programme

Adult immunisation2.  To identify possible interventions to increase uptake

Adult immunisation(influenza + whooping cough in pregnancy)

Funding body: NIHR HTA programmeDuration: Sept. 2013‐Dec. 2015

Design & MethodsThree‐phase qualitative study, underpinned by the socio‐ecological model of health promotionecological model of health promotion

• Phase 1: semi‐structured interviews with members of six Travellerwith members of six Traveller communities

• Phase 2: semi‐structured interviewsPhase 2: semi structured interviews with service providers

Framework analysisFramework analysis (within and cross community analysis)

• Phase 3: consensus methods used in facilitated workshops• Phase 3: consensus methods used in facilitated workshops to agree a prioritised list of interventions

Phase 1: Traveller interviewsPhase 1: Traveller interviews

174 Travellers from six 

Scottish Showpeople

communities in four cities

Scottish ShowpeopleSlovakian/Romanian Roma

Glasgow

York

English Travellers

York

Irish Travellers

Bristol London English Gypsies/Irish TravellersRomanian RomaRomanian Roma

Phase 2: Service provider interviewsPhase 2: Service provider  interviews

39 service providers across the four cities

Frontline Workers Strategic/commissioning roleFrontline Workers Strategic/commissioning role

Health VisitorsPractice Nurses

Health ImprovementPublic HealthPractice Nurses

Community MidwivesSchool Nurses

GP

Public HealthImmunisation

Heads of Primary Care & C it S iGPs

Community WorkersCommunity Services

Clinical Commissioning Groups

Phase 3: Consensus Workshopsp

Researchers identified potential interventions from interviews in Phase 1 and Phase 2

Met with Travellers ( 51) t di d

Met with service providers (n=25) to 

(n=51) to discuss and rank interventions

p ( )discuss and rank interventions

Travellers and Service providers shared rankingsTravellers and Service providers shared rankings.Agreed prioritised list of potentially feasible and 

acceptable interventions p

Scottish FindingsScottish Findings

• Slovakian and Romanian Roma

• Scottish Showpeople

Slovakian and Romanian RomaBarriers Facilitators

• Limited understanding of importanceof  vaccination for teenagers /adults

• Concerns about vaccination, in some, linked to ‘bad experiences’ in country 

• Most positive about immunisation• Positive trustful supportivep y

of origin• Teenage girls not in school, pregnant 

women who book late ‘slip through

• Positive, trustful, supportive relationships with members of the specialist EU team (health visiting service)women who book late  slip through 

the net’• Limited number of interpreters who 

speak Romanian and/or Roma

service)• Commitment of school nursing 

service, local schools and home support workersspeak Romanian and/or Roma

• Lack of understanding of how the NHS worksL k f lt l i

support workers• Input from interpreters and bi‐lingual 

support workershi ki (• Lack of cultural awareness in some 

professionals/frontline staff• Poor sharing of information between 

Sl ki /R i d S l d

• Partnership working (EU team, GP Practices, schools)

Slovakia/Romania and Scotland• Low levels of literacy common

Suggestions for Interventionsgg

P t t/ id f di f thIncrease provision of and access to 

i t t d/ bili lProtect/provide funding for the specialist EU team

interpreters and/or bilingual support workers, especially Roma/Romanian speakers

Improve links between healthUse of pictorial communication aids

Improve links between health services in Slovakia/Romania and 

Scotland/UK

Introduce a named person in GP f l k f d ld f b h practices to facilitate uptake of adult 

immunisations and those for teenage girls not in school

Provide information about the NHS in Scotland/UK

Scottish ShowpeopleBarriers Facilitators

• Concern about the MMR linked toConcern about the MMR, linked to children within the community whose parents believe their child’s autism caused by the vaccineautism caused by the vaccine

• Lack of information or misinformation

• Most believed immunisations were important to prevent disease

• Limited time to discuss immunisation with professionals

• A fear of needles in some

• Current level of travelling is limited (mainly in summer months); friends/family access mail A fear of needles in some

• Failure to receive letters/reminders (shared mail box in yards)

letters/reminders for immunisation

• Feelings of discrimination when communicating with professionals (rare, but experienced)

Suggestions for Interventionsgg

Trusted information on social media  Professionals to make greater use of l fl t d 1 t 1 i tito address knowledge gaps and 

fears about specific immunisation

leaflets and 1‐to‐1 communications to address knowledge gaps/fears about specific immunisation

Training for professionals to help h id if i / l i

Flexible approach to sending i d i d hthem identify anxious/selective 

vaccinators and develop confidence in discussing concerns

appointments and reminders when vaccinations are due (e.g. texts, 

phone calls)

Cultural awareness training forCultural awareness training for health professionals and frontline 

staff

Next Stepsp• To discuss findings with key stakeholders in Scotland

and to agree potential interventions to address barriersand to agree potential interventions to address barriers to uptake of immunisation

Plans at a UK ide le el incl de the de elopment and• Plans at a UK-wide level include the development and evaluation of a National Policy Plan

Copies of the Health Technology Assessment (Final Report and summaries) from:(Final Report and summaries) from:

s.m.kerr@gcu.ac.ukoror

http://www.journalslibrary.nihr.ac.uk/hta/volume-20/issue-72

Co‐applicants/collaborators

h f d d b h l f l h h l h h lThis project was funded by the National Institute for Health Research Health 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 HTA, NIHR, NHS or the Department of Health