When the national COVID-19 vaccination programme began in December 2020, it was understood that everyone should have equal access to the vaccine, as appropriate to their need, and as prioritised by the Joint Committee on Vaccination and Immunisation. Within a few weeks however, there were early indications that there were differences in uptake amongst different population groups and in different parts of the country (The OpenSAFELY Collaborative 2021).
As a result of these differences, many local examples of initiatives to increase vaccine uptake began to emerge. The Health Inequalities Improvement Team in partnership with the Vaccine Equalities Team at NHS England and Improvement commissioned the Strategy Unit to collect and collate some of these examples in a structured way.
What we did: using social media channels and professional networks we identified and requested a half hour conversation with people involved in initiatives to increase local vaccine uptake. We spoke to people in March-April 2020, involved in 50 different initiatives across England and wrote up each of these individual accounts in a structured way.
The examples we collected focused on four target groups: place of residence, ethnicity, faith communities and health status and could be grouped as two main types of intervention: information and outreach. Representative examples of each of these are included as case studies on the NHS England website, all 50 examples can be viewed below.
A blog outlining the three key lessons for working with communities beyond the vaccination programme is hosted on the NHS Confederation website.
Where a person lives, especially if the accommodation is temporary or unstable, can strongly impact on health and access to healthcare services. The seven examples provided below were targeted at people experiencing homelessness, were prisoners, or migrants and asylum seekers.
Based on our discussions with people working on these initiatives to increase vaccine uptake, we found the following aspects to be key:
Taking the vaccine to the person. Local charities and housing organisations are playing a vital role in identifying who is homeless and the barriers to them accessing the vaccine. This is based on their pre-existing relationship and the trust built with their local homeless community. Outreach is particularly important. It is crucial that initiatives ‘go to’ these populations, by offering the vaccine in hostels or shelters or other less formal spaces (such as soup kitchens). Offering the vaccine at different times of the day or night is also important, to account for people who have different routines. As is returning to the location on a different day, to reach people who were not present on the first visit.
Trusting the system. Mistrust of the government and the NHS is a particular problem, especially for some asylum seekers who believe their residence in the UK could be compromised by registering with a GP or accessing the vaccine. There are concerns that data will be shared between the NHS and the Home Office. To overcome this, it is vital to consider who is attempting to improve vaccine uptake, it is more likely to be effective when originating from within the community.
Awareness of the processes. One of the main barriers to vaccination is accessing an appointment. To obtain an NHS Number, people need to register with a GP. In practice this presents two challenges. Firstly, some people are not aware that they are entitled to register for a GP and secondly, the GP surgery may not be aware that they can register people who do not have a home address. Raising awareness of this issue in general practice will provide an opportunity to incorporate people into the healthcare system who may have never previously engaged with it.
People from minority ethnic groups are at higher risk of COVID-19 infection. They are also at higher risk of more severe disease resulting in higher mortality. The 11 examples below targeted communities by race, ethnicity, language and culture.
Based on our discussions with people working with minority ethnic communities to increase vaccine uptake, we found the following aspects to be key:
Building trust through representation. It is beneficial to have information about the vaccine delivered by someone that is representative of the community being served. Collaboration with community representatives, including people proficient in different languages who can address cultural concerns as well as clinical ones, has provided an opportunity to build trust in local health and care systems to encourage vaccine uptake. Using already visible community figures in information sharing has built further trust. This investment in developing trusting relationships is seen to be valuable for reducing health inequalities in the future.
Listening to concerns. Often health leaders make certain assumptions about why there might be poor vaccine uptake among some communities. Understanding the differing root causes of vaccine hesitancy, even if they are unrelated to the pandemic or vaccinations, enable efforts to be better tailored towards community concerns. Acknowledging the lived experience of systemic racism is an important step for reducing distrust in the vaccine. This initiates a two-way communication where individual concerns are recognised and addressed with facts.
Sharing information. Despite national and local campaigns, vaccine information had not reached everyone equitably. Feeling overwhelmed by information has been recognised as a contributor to vaccine hesitancy in minority ethnic groups. Word-of-mouth is powerful in communities where English is not spoken by all. Providing translated resources and bilingual staff at vaccination sites are helpful in overcoming communication issues. Information resources translated into different languages are often in ‘pure language’ which is difficult for people who speak in a specific dialect to understand. Involving the target population in the design is necessary to ensure that the information is fit for purpose. Social media, such as community WhatsApp groups, has proven a useful tool for sharing information about the vaccine.
Knowledge of how specific faith communities engage with healthcare services is very limited. Religious identity in this context is often hidden within the intersectional elements of race, ethnicity or culture. Eight of the examples below were targeted at faith groups.
Based on our discussions with people working with faith groups to increase vaccine uptake, we found the following aspects to be key:
Faith leaders. Local faith leaders are playing a pivotal role in promoting vaccine uptake in their communities. They are also working with NHS colleagues to ensure the vaccine messaging, promotion and delivery meets the needs of their communities. Their active involvement in tailoring vaccination efforts for religious communities is universally recognised as an important feature of local vaccination drives. Faith leaders are considered be the best placed, and the most credible, in recognising and addressing the different religious beliefs associated with the COVID-19 vaccination for their communities.
Community Engagement. Many faith communities see it as their religious duty to help others in their community or neighbourhood. Local vaccination efforts have provided people with an opportunity to fulfil this duty. This is further strengthened in communities where there has been prior and visible community engagement to improve health outcomes. Some areas have been able to accelerate the vaccination drive through using pre-existing relationships between local healthcare professionals and faith communities.
Places of worship. The use of local places of worship as a vaccine clinic site has encouraged more people from religious communities to take up the offer of the vaccine. Places of worship are more easily accessible for all local people (not just for those from the specific faith group). They also provide access to a trusted person, an opportunity to discuss vaccine concerns with someone who they find credible, both clinical and non-clinical. Following the first dose in a place of worship, people are happy to book in their second appointment in a more usual setting as their vaccine concerns have been addressed.
In the first weeks of the vaccine roll-out, patients with pre-existing medical conditions did not receive equal access to the vaccine. We collected eight examples which targeted people with disabilities or long-term medical conditions.
Based on our discussions with people working to increase vaccine uptake for people with specific health conditions, we found the following aspects to be key:
Conversations based on trust. People with specific health care needs require opportunities to discuss their personal concerns with healthcare professionals they already know and trust, such as their GP or specialist. This is important in addressing individual concerns and building confidence that the vaccine is safe for them. For example, early COVID-19 critical care guidelines were viewed as lacking parity for people with learning disabilities, this in turn led to mistrust for the vaccine. Support from voluntary organisations who hold a trusted position and existing relationships are valued. They can listen to people’s concerns about the vaccine, and then collaborate with medical professionals to improve the approach to vaccination.
Tailored information. Co-design and sharing of information enables critical gaps in information provision to be identified, addressed and tailored. Information and education initiatives also need to account for the greater digital and social exclusion that many people with a health condition and disability experience in addition to their specific communication needs. Modified written information such as Easy Read versions has made vaccine information easier to engage with. As have alternative forms of media such as videos, dramatised stories and both physical and digital resources. Creativity in communication has also been effective in overcoming communication barriers. For example, an app providing immediate access to British Sign Language interpreters.
Accessibility of vaccination sites. People with complex health conditions or disabilities need more time to prepare for appointments, with clear details of the appointment being provided well in advance. Appointments offered verbally and at short notice can create additional anxiety. Vaccine clinics that are based in familiar and quieter locations, such as GP surgeries and community venues, provide a more accessible alternative to mass vaccination centres. Premises with the flexibility to offer extended appointments that can also be attended by carers are particularly effective in increasing uptake. Combining the vaccination appointment with other health checks provides an opportunity to assess more holistic health needs of the person.
Lack of relevant information, concerns around side effects and the confusion caused by misinformation are cited to be reasons for vaccine hesitancy. 25 of the examples collected were information and education-based initiatives.
Based on our discussions with people delivering information and education-based initiatives to increase vaccine uptake, we found the following aspects to be important:
Engaging in conversations. Many information sharing examples begin with a two-way communication or dialog between the health and care professionals, or their community advocates, and the group being targeted. This listening and engagement has allowed for a richer conversation to occur and awareness of issues that were previously unrecognised. This conversation is especially important for people and communities who have traditionally had lower access to health services and those with high levels of mistrust in the government or healthcare organisations. Medical professionals, especially GPs that represent the community being targeted can often be the best placed to address individual clinical concerns. These have been provided through a one-to-one conversation. Good engagement has led to the co-design of tailored materials targeted to specific information needs.
Confidence in delivering the information. Trusted peers are playing a critical role in providing tailored information to their communities. These individuals, with their local knowledge are able to respond better to the information and communication needs of their community. However, they may not necessarily recognise themselves as community champions or leads and require initial support and skills-training from health and care professionals, to confidently deliver reliable and factual information back to their communities.
Communicating effectively. Information around the vaccine was communicated via posters, webinars and videos, and shared through familiar and routine channels including social media. Written information is not always the most accessible and communication through videos or infographics can be more helpful. Regardless of the format, information which is translated into the community languages including British Sign Language, and communicated in easy to read and in less formal and more everyday language is more valuable. In the information communicated, it is more effective to provide the facts, acknowledging or repeating any misinformation could further confuse or reinforce vaccine myths.
Using typical or traditional healthcare settings to give vaccines may disadvantage some people. 25 of the examples we collected took the vaccine to specific groups of people.
Based on our discussions with people utilising outreach approaches to increase vaccine uptake, we found the following aspects to be key:
Tailor the approach. Bringing the vaccination closer to local communities has supported easier access and encouraged more vulnerable and harder to reach populations to take the vaccine. Utilising local clinicians, trusted community figures and local services who understand the needs of target populations and the barriers or concerns faced with accessing vaccinations has been paramount when tailoring vaccination approaches. For example, there is a preference for many communities to go to a familiar place as it makes them feel safe and some groups might be more readily available to take the vaccine at particular times of the day.
Involve healthcare professionals from the community. Vaccine uptake is higher when healthcare professionals who are representative of the communities lead vaccination efforts. They may make initial contact to invite individuals for the vaccination or share their experience of taking the vaccine. Involving a healthcare professional to administer the vaccine who resembles the community served, provides further confidence to take the vaccine. The visible presence of a clinician from the community, particularly at pop up or mobile clinics further encourages people to engage in a meaningful and relevant conversation for them.
Maintain community activities. Co-delivering vaccine initiatives with community members such as those working at vaccine venues and sustained promotion of local vaccination drives has accelerated vaccine uptake. Being visible to people walking past and being ready to engage in conversation, especially at mobile clinic sites has further encouraged vaccine uptake. Continuity and consistency of messages in the preferred language of the target population via community channels, WhatsApp groups or social media networks has been pivotal to local vaccine advertising campaign.
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