A1: These are the most difficult groups, many of whom may have difficulty accessing the healthcare system and even fear possible repercussions. The difficulties are clear and can only be addressed by NGOs and social workers in health centers. In addition to lack of access, another possible factor is the poor education and in particular the poor health education that these populations have. Especially and even more importantly in preventive measures such as vaccinations.
In addition to these more extreme groups, there would also be difficulties on the part of socially disadvantaged groups; in these groups there may also be phenomena such as lack of access for reasons of time or convenience, leaving work to get vaccinated is not well regarded and the person himself will not prioritize it over other possible treatment measures (if they were to need them). This point is something that we have seen in Spain, for example for the vaccination against COVID-19 in fruit and vegetable workers in general was done by means of devices that went to the companies to vaccinate so that they did not have to interrupt their work, in case of having had to go to a health center many of these workers would not have been vaccinated.
Most outreach efforts around vaccination in Southwark have focused on reducing inequalities in uptake between ethnic groups and health inclusion groups such as asylum seekers, or hyperlocal approaches to areas of low uptake, rather than on poverty explicitly.
Local success can be difficult to measure, with challenges around evaluating the impact of local programmes vs national programmes (particularly during the height of the COVID-19 campaign), however it appears that the below approaches have had a positive impact on vaccination uptake among those facing social exclusion and those experiencing poverty.
ď§ A community health ambassador programme to build trust in vaccinations by training trusted community voices to share accurate information about vaccination, and bust myths in their communities, both face to face and on social media.
ď§ Co-producing information around vaccination with local voluntary sector organisations and faith groups proved successful during the COVID-19 vaccination campaign, and in campaigns around other vaccinations. For example, we worked with Southwark Refugee Communities Forum on the polio booster campaign, which allowed us to reach supplementary school for Spanish-speaking, Somali-speaking and Farsi-speaking children in the borough, who had not been reached with English language communications.
A3: With all of these approaches, it is really important to emphasise local ownership, continuity and sustainability. Too often programmes and interventions are designed within the short-term and fail to adequately involve the populations being researched. In addition to falling short of achieving meaningful change and advancing equity, this can cause lasting harm on the communities and populations at the heart of the issue, who experience research fatigue and disillusionment. We need research funders and donors to recognise this and re-design funding calls with longer term goals and community-centred frameworks for participation and implementation in mind. We also need researchers and policymakers to be cognisant of the risk of causing research fatigue in communities who are endlessly consulted and offered little in return, and to employ more equitable approaches. Communities affected by vaccine inequities are experts by experience and may hold many of the answers we are looking for - it is essential that their lived experience, knowledge and skills are recognised, harnessed and valued, and community members are appropriately compensated for their contributions.
A2: Basically the same as described above, poor health education, possible lower access to the health system, less importance of preventive measures, working conditions that make access to the health system difficult (especially for vaccines that are usually administered at the same time as working hours), the need to request an appointment for vaccination, limited vaccination schedules (only in the mornings and generally not on weekends), etc.
In general, conditions in urban and rural areas may be similar, depending on issues such as distance to the health center and work.
In addition to these examples, I am also pleased to point out what has recently been achieved by my organisation, Cittadinanzattiva, in Italy.
Message summary: We continue to observe persistent conditions of disparity in access to treatment, including vaccines, and we are increasingly aware that the health of every single person is interconnected and that to protect everyoneâs health, no one can be left behind. The pandemic has turned the spotlight on issues we have been talking about for decades, starting with the link between health and the environment, the close connection between the socio-economic and education levels of individuals and the state of psychophysical health of citizens, the growing weight of inequalities in achieving guaranteed health goals everywhere. Now we must ensure that the containment of the pandemic and the serious war scenarios in which we are immersed do not turn off the spotlight on these issues. Also for this reason, Cittadinanzattiva has created the first âCivic Charter of Global Healthâ. Global Health is an approach that aims to give full meaning and implementation to a vision of health as a state of bio-psycho-social well-being and as a fundamental human right.
In Nepal, consistent community engagement has contributed to an overall increase in routine childhood immunization. Community engagement is led by the Ministry of Health and Population and implemented through community-led committees that ensure âbottom-upâ feedback. These committees are made up of diverse stakeholders â including hard to-reach communities â and support the development of tailored messaging and outreach that takes into consideration
cultural, religious, and geographic contexts.
Clearly the polio vaccination campaigns have been very successful in reaching almost all segments of the population â although it has taken time and met with significant pockets of resistance to uptake. Polio itself, as a disease, is very strongly linked to poverty â poor sanitation, inadequate nutrition and access to healthcare â so the campaign against polio inevitably focused on areas with significant levels of poverty. India is a particularly illustrative example here though I think â up until 1995 this was a country that still had up to 150,000 cases a yearâŚ15 years later it was gone!
Broadband internet access is considered a âsocial determinant of healthâ. Many healthcare providers use online systems to schedule appointments; as a result, lack of internet access has been suggested as a barrier to vaccination. In New York City, COVID-19 vaccination was shown to be significantly associated with internet access.
Michaels IH, Pirani SJ, Carrascal A. Disparities in Internet Access and COVID-19 Vaccination in New York City. Prev Chronic Dis 2021;18:210143. DOI: http://dx.doi.org/10.5888/pcd18.210143
A3. In Beirut UNICEF successfully manage to bring services to Syrian refugees (most of whom are paperless) , living in poor neighbourhoods to get children vaccinated and attending preschool. This is a done by walking door to door, and building âtrustâ. And by offering convenient and free services nearby.
A3: Various studies showed that engaging at a community level are very effective. For example, engaging religious leaders, churches and mosques and penetrating communities and leaders has shown to increase uptake.
Agreed! Trust is key. If people do not trust in the scientists, healthcare professionals, governments, policy makers, and systems that develop, deliver, and mandate vaccines they will look for alternative sources of information. While we may not be able to combat all the conspiracy theories or misinformation running rampant on social media, we can restore trust in reputable sources.
Other interventions we have implemented are:
|ď§|Working with Community Links to arrange a foreign language call and recall service for COVID-19 vaccination for persistent decliners/DNAs.
|ď§|Vaccination pop-ups in high footfall locations in areas of low uptake that combine immunisations with other health and wellbeing support such as health information and blood pressure checks.
|ď§|The Southwark Stands Together workstream, launched following the death of George Floyd, that focused on listening to our communities about their experiences of systemic racism, including in the healthcare system.
|ď§|Community researchers embedded in communities, as well as external researchers, carried out research and ethnographic suryeys about barriers to vaccination specific to Southwark communities, in order to inform hyperlocal public health interventions.
In Canada, the province of Nova Scotia enacted policies to universally fund influenza vaccines and allow pharmacists to provide immunization. Studies suggest that these two policy interventions led to increased coverage, particularly for underserved rural populations.
A3: On the supply-side, investments are needed to increase immunization in the poorest countries and among the poorest people. That means not just providing doses but investing in the sharing of supplies, technology, patents, etc., to ensure developing nations have the ability to make their own vaccines. In high-income countries, where vaccines doses are readily available, investments need to be made in ensuring vaccines are affordable to people living in poverty. In places like the U.S., this may require a systemic change and shift towards universal health care.
I am hard pressed to think of a successful example that meaningfully addresses supply-side barriers. COVAX, which aimed to guarantee the fair and equitable access of COVID-19 vaccines globally, attempted to address vaccine nationalism during the pandemic, however, the promised targets often fell short, and doses were still severely delayed to many low-income countries. While COVAX was a vital band aid, it isnât a solution. I donât mean to criticize COVAX, but rather to point out that an opportunity still exists for the business sector to creatively contribute to developing a solution(s)âone that doesnât rely solely on charity, one that empowers and builds the capacity of people and countries, and one that prioritizes social impact over individual profit (that last one may just be wishful thinking).
A3: In terms of demand-side barriers, this to me is more challenging and nuanced and will require more time, especially in restoring trust. There is certainly no âone-size-fits-all solution. Meaningful collaboration and leadership between multi-sectoral partners and the communities impacted (recognizing the expertise of the communities we serve is foundational) will be imperative, as well a great deal of patience and fortitude. Below are a couple of examples. They donât specifically relate to people living in poverty or social exclusion but could be adapted. The first addresses confidence barriers to vaccination uptake in real-time and the other is an example of long-term investment and the everyday payoff as well as in terms of preparation for times of crisis.
Ex. 2: Portugal has one of the highest vaccine uptakes globally, the result of a national immunization program that ensures recommended vaccines are readily available, accessible, and affordable. The program grew out of the countryâs devastating experience battling polio in the 1950âs and 60âs. Portugal has one of the top vaccination rates but isn't taking chances with omicron : NPR