Why local initiatives matter in vaccine outreach

Emma Wilkinson looks at some local initiatives to tackle poorer vaccine uptake among under-served groups

This is an edited version of an article that originally appeared on The BMJ

In leafy East Sussex the rates of those who have had their first and second doses of COVID-19 vaccine are 80% and 65%, respectively. Conversely, in Newham in east London, the rates are 44% and 26%, according to the government dashboard.

Given the higher transmissibility of the delta variant, and lower vaccine uptake among some of those most vulnerable to COVID, including some ethnic minority groups, this disparity is worrying, says Farzana Hussain, a GP in Newham.

Early on she noticed that only about half of her patients aged over 65 were coming forward for vaccination so she started to call them one-by-one. “I wanted to ask if they had any questions and I found there was a lot of misinformation. The overarching concern back then was about safety, and we had to debunk myths around it containing animal products,” she says. “Looking at my practice levels, we now have around 80% of the over 65s vaccinated. It’s the rate of younger people with long term conditions that’s not as high – although we’re still above average.”

The concerns have changed over time, she adds. “Younger people are more worried about fertility but, as we move down the cohorts, it’s more ‘Why should I have it? I’m not at risk.’”

Keeping it local

Reports from community level suggest that vaccine confidence among ethnic minorities is improving; the national picture, however, suggests that more work needs to be done.

Samia Latif, consultant in communicable disease control and chair of the Black and Minority Ethnic Network at Public Health England, says that, in December, a consortium of more than 40 ethnic minority health professional networks worked to identify the underlying concerns around vaccine uptake in their communities and share good practice. “COVID has made everyone realise that you can’t leave anyone behind. We knew we needed to talk to all these communities, and really understand their concerns, but also that they needed to trust the person the message is coming from,” she says. Samia stresses that these are not “hard to reach” groups but historically under-served populations.

Salman Waqar, a GP who has worked on vaccine initiatives with the British Islamic Medical Association, says it boils down to a matter of trust, and helping people to navigate all the contradictory advice they’ve been hearing. “What we’ve been trying to do is recognise that we’re not operating in a vacuum – we have to validate concerns around inequality and inequity – but there was also targeted disinformation about things like whether the vaccine is halal or, in the Christian community, about whether the vaccines contained aborted fetal cells.”

He believes a local response is key but says it is resource-intensive. As time has passed it’s not so much the fringe views that people are airing, but legitimate concerns about safety, effectiveness and side effects. “We’re not going to undo decades, if not centuries, of inequalities in 18 months,” he adds. “There’s a lot of institutional memory about being used and abused, for want of a better phrase.”

In Sheffield the city council and clinical commissioning group have invested more than £300,000 in over 30 community groups. There have been pop-up clinics in mosques, hostels, and a supermarket, and a vaccine bus which has travelled around areas of high deprivation. Sheffield has about 66% uptake of a first dose—a good percentage for a city—but uptake remains lower among some communities including black African and African Caribbean populations.

The investment in community and voluntary organisations has led to “incredible message delivery about effectiveness and safety in ways that are far more nuanced,” says Greg Fell, Sheffield director of public health. “Local knowledge, contacts and credibility really, really matter,” he says. Sometimes it can be small things, like organising transport, that gets people over the line, he adds.

Covering all bases

Gulnaz Hussain is chief executive of the Firvale Community Hub, a charity working to improve social equality and inclusion by, for example, providing advice on welfare rights and housing. The areas of Sheffield she works in are some of the most deprived in the city, and were hit hard by COVID – yet people often weren’t accessing public health information.

“We’ve done a lot of work around vaccination. We had NHS training and we had a health co-ordinator who was making sure the messages were getting out. We also opened a vaccine helpline, available in community languages. As we move on to younger age groups, we’re doing work with youth centres and youth clubs.”

She says they use any and every opportunity to provide information – often when people are seeking advice on welfare or immigration. “We’re able to convince them, and we can speak to other family members who might be saying not to get the vaccine.” At the hub they ran a successful vaccination clinic for the Roma community, and they have plans for others.

In Bristol, community pharmacist Ade Williams has worked hard across social media, and in person, to dispel myths being propagated by a ‘vocal anti-vaccination campaign’. He has spoken to different faith groups and the traveller community, taken part in a Facebook video and, most recently, been involved in efforts to promote the vaccine through pubs and hairdressers. Uptake in Bristol City is just under 60%, with 40% having had two doses.

Ade runs a vaccination site in a Methodist church and, from day one, has encouraged people to pop in, take a look, and ask questions. “Some people have anxiety about vaccination itself, so that helps,” he says. “Sometimes people are struggling to navigate the booking system. Everyone has questions about safety – and fertility, that one carries on. I’ve also had to reassure people that they will not be compelled to have it; our healthcare system will always give you a choice.”

He says it’s important not to get frustrated but to have compassion for populations where health inequalities have never been properly tackled. “If no-one has ever acknowledged you and, all of a sudden, everyone’s trying to drag you into the room, of course you will think, ‘Hang on a minute’. We have to understand that and work with people.”