Dan Paskins at Save the Children mentioned to me recently – 'we need to switch our mindsets about ‘hard to reach populations’….need to think its actually that the institutions are hard to reach for some people…
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There is also a large, and growing, urban poor population around the world with significant health needs
• The global trend towards urbanization continues, often overlapping with rapid population growth.
• Urban poverty is closely linked with increased risk of vaccine-preventable disease
• Note though that the definition of poverty changes based on country context, influencing size of target population.
Urban poor in HIC such as in most of Europe tend to present a more static population, often defined by entrenched pockets of poverty among marginalized minority groups coupled with under-investment in urban infrastructure.
• Vaccination hesitancy is an increasing driver of lower vaccination rates
• Systemic and structural barriers lead to access issues among already marginalized populations
• There are pockets of unvaccinated populations, including communities of color, migrant populations and people with disabilities.
• High income countries may require a more nuanced definition of poverty and / or social exclusion to identify at-risk populations.
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Access and the need for adopting different interventions according to the urban-rural variations. Alternate mechanisms to access health and social affairs such as in Belgium, a kiosk intervention was used which was found to be a more approachable, less clinical, scaremongering and user friendly.
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To all this, it should be added that in the aftermath of the first wave of the pandemic, the vaccination centres reopened, but in many cases with reduced opening hours to the public, as denounced by my association Cittadinanzattiva, which continues to record cases of non-access to vaccination centres also in 2023. I add 2 links (IT language): https://www.ansa.it/canale_saluteebenessere/notizie/focus_vaccini/2022/01/26/cittadinanzattivapandemia-allunga-attese-vaccini-non-covid_a4ba06c1-d28a-497b-9155-20d6ca311a7c.html; Lamezia, centri vaccinali non più in attività: 90enne arriva fino... ad Aprigliano - Gazzetta del Sud
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A2: Are there any current information campaigns happening in Italy that have been successful? Would love to have a reference point as an example.
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A2: To Alison’s point social media is use the source of information.
Misinformation on vaccination: A quantitative analysis of YouTube videos.
In Italy, the phenomenon of vaccine hesitancy has increased with time and represents a complex problem that requires continuous monitoring. Misinformation on media and social media seems to be one of the determinants of the vaccine hesitancy since, for instance, 42.8 percent of Italian citizens used the internet to obtain vaccine information in 2016.
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A great check-list for us all to start addressing!
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We experience this in our population too. We also find it can be different depending on the vaccine e.g. more hesitancy re COVID or MMR compared to others.
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Agree, we need to change the language we use around this.
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Yes, completely agree… or easy to ignore…
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Here you are some examples: 1) In Italy, Intersos has worked to facilitate access to the vaccination campaign of the migrant population in the areas of Rome, Foggia and also in other territories, in collaboration with some local associations, carrying out, in addition to its health projects, also vaccine awareness activities for Italian and foreign people who live in situations of marginalisation and giving direct support, thanks to cultural and linguistic mediators, to people without a health card to book the vaccine and to obtain the green pass often hindered by bureaucratic obstacles. 2) “On the Road” anti-Covid vaccination campaign to protect homeless people who live on the street and who do not have the possibility of accessing the vaccine following traditional channels. Launched by the Progetto Arca association in a pilot phase at the beginning of August 2021, the campaign stems from the collaboration between the Municipality of Milan, the NGO Sector, Ats-the Agency for the Protection of Health of the Metropolitan City of Milan, Areu-Regional Emergency Agency Urgency and the Lombardy Region and took place from 6 to 30 September 2021. The single-dose vaccine was administered, therefore it is not necessary to make the booster, always difficult when dealing with the homeless. At each medical camp, people receive informed consent, available in Italian, English, French, Arabic or Romanian, the medical history, pre- and post-vaccination checks and the vaccination certificate.
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UNICEF works with search engine companies to put “reliable” vaccination information sources at the top of the answers - but long way to go here. And we need to realize that active spread of misinformation is here to stay. But it can be studied and addressed.
We need to remember that vaccines do not protect, onlvy vaccinations. And that requires accesible services and TRUST in those services.
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Trust is a key component of vaccine confidence, and for many, the messenger is as important as the message. Expanded and co-created community-specific health literacy and vaccine awareness campaigns, delivered by trusted messengers, are needed to reach the vaccine-hesitant and combat a rising tide of mis- and dis-information. Leaders can build trust in immunization programs by developing robust communication strategies and responding to direct public concerns with clear messages based on scientific evidence as part of a national strategy to increase acceptance and demand for vaccination.
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For me, complacency needs to be adjusted for people living in poverty or social inclusion. Instead of seeing no major risk from a disease, people living in poverty or socially excluded groups may feel that taking time off of work to get vaccinated may be the bigger risk. There may be competing needs that take precedence over vaccination, like securing food and shelter. Getting vaccinated may feel more like a luxury than a necessity. For socially excluded groups, I am thinking of migrant groups in particular, it may also be that the risk of the disease is too low to justify risking personal safety.
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Message in summary: Vaccines on the street for the homeless: no one should be left out. More info here: Vaccini in strada per i senza dimora. Nessuno deve rimanere escluso
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Ok lets get going with Q3 What examples are you aware of that have successfully reached those living in poverty or social exclusion with vaccinations….
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A3: Empowering the communities directly affected by poverty and social exclusion to identify and implement novel solutions that work for them is one of the most promising approaches and puts power back in the hands of those who have been marginalised. A big focus of our work in the Migrant Health Research Group at St George’s, University of London, is on using participatory research approaches to co-produce interventions and services with migrant populations that are better tailored to their needs. Participatory research promotes inclusivity and power sharing in conducting research by actively involving those affected by the issue being studied as equal partners in the research process and can lead to transformative change. Embedding participation in the quest to tackle vaccine inequities is potentially very powerful, as evidence shows that interventions driven by insights from the communities they are designed to serve are more cost-effective and lead to better results for health behaviour outcomes than traditional interventions.
In our participatory study with Congolese migrants in London, we formed a community-academic coalition to design and implement a study to strengthen COVID-19 vaccine uptake, which led to the community co-producing three interventions tailored to their preferences and needs: community-led workshops and meetings about COVID-19 vaccination and wider health needs; plays about COVID-19 vaccination; and posters of local vaccination champions. In addition to high engagement with the study activities and acceptability of the interventions, anecdotal evidence suggests that the participatory nature of the study and providing a friendly, non-judgmental space to talk about COVID-19 vaccination with trusted members of the community increased uptake of the vaccination in many people who were initially hesitant, demonstrating the power of a community-engaged, participatory approach. The World Health Organization (WHO/EURO) also promotes a tailored approach through their Tailoring Immunization Programmes tool. You can read about more examples at the link.
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A3: Other success stories include addressing the barriers highlighted above at individual, social, organisational and policy levels. Physical access barriers can be overcome by bringing vaccination services into the community and by engaging with community leaders and champions who have better access to and may be more trusted by marginalised members of society. Legal barriers can be addressed through a shift to more inclusive policies, which proved successful during the COVID-19 vaccination drive. For example, recognising the real and perceived legal barriers felt by many migrants, many local authorities in London and the UK actively encouraged undocumented migrants and homeless people to come forward for COVID-19 vaccinations reassuring them that they would not face legal or financial consequences.
There is also the need for clearer guidance on offering catch-up vaccinations to migrants and other under-immunised groups, and systems in primary care to facilitate this. At St George’s, University of London, we are leading the implementation and testing of an innovative tool called Health Catch Up to guide decision-making in primary care around catch-up vaccination offerings to migrants.
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A3: Various studies have shown that face-to-face communication and outreach, initiatives that build trust and share responsibility through local partnerships, and cultural competence of healthcare providers can facilitate vaccine uptake in migrants. In Sweden, for example, all newly arrived migrant children are invited to meet with the school nurse to determine health and vaccination needs, helping to establish trust early. In London, UK, the delivering population-wide COVID-19 vaccination programme was led by the NHS and delivered through partnerships at citywide, ICS, borough, locality and hyperlocal level. Information provided by community champions at grassroots level was essential to tailoring delivery. The vaccine was made more accessible through:
- Flexible booking approaches, appointments and walk-ins
- Innovative transport and outreach models to reach vulnerable groups (e.g. targeted outreach working closely with local community and faith groups; collaborations on homeless health with drug/alcohol agencies; mobile vaccinations)
- Pop-up clinics informed by data where people needed them
- Using accessible community-based venues
Engagement with Chinese community leaders and advertisement on online message boards for Chinese speakers about free jabs without need to present any documents led to high uptake of COVID-19 vaccination by undocumented migrants at a London Chinatown pop-up COVID-19 clinic in 2021. COVID-19 vaccination sessions were hosted by Hatzola, the volunteer ambulance centre run by the Orthodox (Charedi) Jewish community in North London (which has also run sessions for MMR and other routine vaccinations), and in mosques and community centres, highlighting the importance of working in partnership with faith leaders and organisations trusted by communities and using tailored messages and local settings.
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