key: cord-0280749-f8a9czg1
authors: Kasstan, B.; Mounier-Jack, S.; Letley, L.; Gaskell, K. M.; Roberts, C. h.; Stone, N.; Lal, S.; Eggo, R. M.; Marks, M.; Chantler, T.
title: Localising Vaccination Services: Qualitative Insights on an Orthodox Jewish Collaboration with Public health during the UK coronavirus Vaccine Programme
date: 2021-09-15
journal: nan
DOI: 10.1101/2021.09.10.21263372
sha: cb1e70a945011fb9eb494a087d99958db98417a7
doc_id: 280749
cord_uid: f8a9czg1

Ethnic and religious minorities have been disproportionately affected by the SARS-CoV-2 pandemic and are less likely to accept coronavirus vaccinations. Orthodox (Haredi) Jewish neighbourhoods in England experienced high incidences of SARS-CoV-2 in 2020-21 and measles outbreaks (2018-19) due to suboptimal childhood vaccination coverage. The objective of our study was to explore how the coronavirus vaccination programme (CVP) was co-delivered between public health services and an Orthodox Jewish health organisation. Methods included 28 semi-structured interviews conducted virtually with public health professionals, community welfare and religious representatives, and household members. We examined CVP delivery from the perspectives of those involved in organising services and vaccine beneficiaries. Interview data was contextualised within debates of the CVP in Orthodox (Haredi) Jewish print and social media. Thematic analysis generated five considerations: i) Prior immunisation-related collaboration with public health services carved a role for Jewish health organisations to host and promote coronavirus vaccination sessions, distribute appointments, and administer vaccines ii) Public health services maintained responsibility for training, logistics, and maintaining vaccination records; iii) The localised approach to service delivery promoted vaccination in a minority with historically suboptimal levels of coverage; iv) Co-delivery promoted trust in the CVP, though a minority of participants maintained concerns around safety; v) Provision of CVP information and stakeholders response to situated (context-specific) challenges and concerns. Drawing on this example of CVP co-delivery, we propose that a localised approach to delivering immunisation programmes could address service provision gaps in ways that involve trusted community organisations. Localisation of vaccination services can include communication or implementation strategies, but both approaches involve consideration of investment, engagement and coordination, which are not cost-neutral. Localising vaccination services in collaboration with welfare groups raises opportunities for the on-going CVP and other immunisation programmes, and constitutes an opportunity for ethnic and religious minorities to collaborate in safeguarding community health.

Ethnic and religious minorities in England have been disproportionately affected by SARS-CoV-2 1 and are also widely reported to be less likely to accept vaccines offered as part of pandemic control measures. [2] [3] High incidences of SARS-CoV-2 have been observed among Orthodox Jewish neighbourhoods in the UK, 4 the US, 5 and Israel. 6 This disproportionate burden of SARS-CoV-2 among Orthodox Jewish neighbourhoods should be understood against a backdrop of previous outbreaks of vaccine-preventable disease, especially measles, which have been attributed to suboptimal vaccination coverage rates. [7] [8] [9] [10] In 2018-19, the largest measles epidemics in a quarter century were recorded in the US and Israel, which originated in New York and were linked to unvaccinated Orthodox Jews travelling between the two jurisdictions. [10] [11] [12] . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted  https://doi.org/10.1101/2021.09. 10 .21263372 doi: medRxiv preprint 4 The World Health Organization ranked vaccine hesitancy as among the top ten threats to global health in 2019, commensurate with the dangers posed by climate change and antimicrobial resistance. As in any population, concerns of vaccine safety exist in Orthodox Jewish families. 9, 13 There is evidence to suggest that a small but globally networked group of non-vaccination activists are targeting Orthodox Jewish neighbourhoods to propagate vaccine safety concerns. [14] [15] Yet, the contemporary public health and scholarly emphasis on hesitancy is in danger of focusing attention on people as problems, rather than examining the accessibility, efficiency and responsiveness of services in minority settings.

Studies consistently report that Orthodox Jews in the UK and Israel have suboptimal access to vaccination services, often because of practical issues with large family sizes, 16-17 which indicates structural issues in service delivery and equity. Recognising that a 'one size fits all' approach would not improve vaccination coverage rates in Orthodox Jewish neighbourhoods in North London, a WHO Tailoring Immunization Programme (TIP) was conducted in 2014 to diagnose barriers and enablers to vaccination and recommend evidence-informed responses to improve uptake. 16 The present study focuses on attempts to optimise the UK coronavirus vaccination programme among Haredi Jews, who are often and problematically termed 'ultra-' or 'strictly Orthodox.'

Haredi Jews share a commitment to living within the parameters of Jewish law (halachah), but form diverse movements characterised by lineage and nuances in customs, stringencies and rabbinic authority. Haredi Jews are self-protective and carefully manage encounters with broader society, 18 which may raise implications for healthcare services. 19 Jewish law does not explicitly . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted  https://doi.org/10.1101/2021.09. 10 .21263372 doi: medRxiv preprint endorse or prohibit vaccination, though rabbinic authorities generally accept vaccination as a safe way to protect child and population health. 20 Jewish law, however, is not always the primary influence on vaccine decision-making among Haredi Jewish parents. 13, 21 It should not be assumed that Orthodox and Haredi Jews will defer family health decisions to religious authorities. 22

Recent studies exploring uptake of SARS-CoV-2 vaccination among Orthodox and Haredi Jewish neighbourhoods in the US report lower likelihood of accepting vaccination and higher rates of hesitancy, and report that primary disseminators of vaccine information should be trusted stakeholders. 23 Considering how convenience and confidence affect use of vaccination services in this ethnic and religious minority, we examine the possibility of localising services in settings that are affected by outbreaks of vaccine-preventable disease. Emerging directly from the data analysis in our study, we define localising vaccination services as collaborating with community health organisations to deliver vaccines in ways that meet the situated (context-specific) needs and expectations of minority groups.

Our premise is that localising vaccination services requires a broader conceptualisation of convenience (a recognised influence on vaccine uptake), defined as 'the degree to which vaccination services are delivered at a time and place and in a cultural context that is convenient and comfortable.' 24 We explore the potential for vaccination services to not only be tailored in a convenient and culturally appropriate manner, but localised and co-delivered with welfare groups that are valued, trusted and managed within minority settings. We suggest that such an approach . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 15, 2021. ; https://doi.org/10.1101/2021.09.10.21263372 doi: medRxiv preprint 6 might simultaneously promote confidence and remove barriers to accessing routine vaccination services and future coronavirus vaccines.

Localising vaccination entails more than attempts to partner with religious and communal authorities, which are recommended in global health delivery strategies, 25 especially as part of mass vaccination programmes in the global south such as polio. [26] [27] Rather, it involves upscaling public health relations with welfare services operated by and for minority groups.

To illustrate a localised vaccination collaboration, we examine the case of Haredi Jewish emergency services that partnered with local health authorities to implement initial coronavirus vaccine drives within their neighbourhoods across the UK. As part of this analysis, we explore perceptions of localised vaccination collaborations from the perspective of public health services and the intended beneficiaries.

This qualitative research was conducted ancillary to a study examining rates of SARS-CoV-2 seroprevalence in a Haredi Jewish population in the UK. 4 Methods consisted of semi-structured informal interviews and discursive analysis of Haredi print media and social media pertaining to the UK national coronavirus vaccination programme. A key strand of the interviews focused on the involvement of 'Hatzola' in the provision of coronavirus vaccines. Hatzola (rescue, save) is a volunteer emergency medical service instituted by and for Haredi neighbourhoods around the world. Haredi Jews view Hatzola as a culturally-appropriate service because their staff and volunteers are Haredi and can communicate health information and respond to questions in . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 15, 2021. ; https://doi.org/10.1101/2021.09.10.21263372 doi: medRxiv preprint vernacular languages (English, Yiddish). Hatzola personnel also wear uniforms and kippot (religious head covering for males), which distinguish them as members of the Haredi community. 28 The London Hatzola branch supported the local coronavirus pandemic response by providing emergency care and public health messages, and hence offered a case study to examine the localisation of vaccine services. Analysis of the data was inductive and thematic, whereby theoretical insights emerge from prolonged engagement with the data rather than being pre-conceived. [29] [30] The data was analysed by BK and TC, who initially coded the same 6 transcripts as a test of reliability. The results were situated in BK's long-term ethnographic investigation into public health relations with Haredi Jewish minorities 13, 19 and TC's research examining barriers to accessing vaccination services. 16 All names of participants, their precise PH roles, and their locations have been anonymised to protect their identities. Ethical approval to conduct this study was provided by the London School of Hygiene & Tropical Medicine (reference: 22532).

Our attention to localised vaccination services raise five key considerations: i) pre-pandemic collaborations to address issues in routine vaccination delivery; ii) scaling up collaborations during the coronavirus vaccination programme and division of responsibility; iii) benefits and limitations of a localised approach for minorities with historically suboptimal levels of vaccination coverage; iv) household responses to Hatzola-hosted coronavirus vaccination sessions; and v) coronavirus vaccine information and responding to situated concerns.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. PH professionals confirmed that the findings from WHO TIP study (running between the years 2015-16) 16 reflected the issues they encountered in seeking to increase vaccine uptake. They stated that access and convenience (e.g. need for flexible clinic times to cater for large families) continued to be the primary issues impeding vaccine uptake rather than vaccine hesitancy. They also added that there was 'a lack of health knowledge in the community' (PH1), which needed to be addressed to promote the value of vaccination in protecting child health. Against the backdrop of the 2018-19 measles outbreaks, some public health workers suggested that improving vaccination coverage rates required greater input from Haredi Jews themselves:

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(PH2) Yet, maintaining sustainable sources of PH funding to continue vaccination programmes in ways that met the expectations of Haredi parents was described as a long-running problem. A clinician noted how staff dedicated to 'call and recall,' who could monitor cases of non-vaccination, such as not attending scheduled appointments, were discontinued, as was the involvement of health visitors in supporting routine vaccination programmes. Inconsistent service provision due to funding limitations was considered by PH staff to engender mistrust on the part of parents making vaccination decisions. PH staff recognised the need for additional financial resources from the central government to deliver vaccinations in minority settings:

'As we say for the 10% of the population or 15% of the population that won't get vaccinated, you have to think differently and it will cost you more money' (PH2).

The scaling up of Hatzola's involvement in the coronavirus vaccine programme was made possible by their role in promoting routine immunisations, and was a direct by-product of providing emergency care and circulating public health guidance to Haredi neighbourhoods throughout the pandemic. It was agreed that a select number of Hatzola-led vaccination sessions would take place in one of the designated and approved local vaccination centres, with a clear division of roles between Hatzolah and PH bodies.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Hatzola hosted these vaccination sessions and had responsibility for promotion, distributing appointments to callers and administering vaccines. Events were also supervised by Jewish healthcare professionals working in the community, which offered continuity between delivery of routine vaccinations and the coronavirus vaccine programme. One healthcare professional suggested that this collaboration meant that Haredi Jews were not just intended beneficiaries of a national vaccination programme, but also had a stake in how the programme was being delivered:

'Public health sort of handed over -at least sufficiently -the front of the campaign to Hatzola so it [...] was actually coming from the Haredi community rather than being imposed on it.' (CR8) PH staff stated that they managed the sessions from 'behind the scenes' (PH3), which meant that PH teams in the UK, maintained responsibility for logistics, training vaccinators, and accurate vaccination records. PH professionals trained 8 male Hatzola volunteers to administer vaccines (and 2 female Jewish healthcare assistants) and ensured sessions operated in accordance with COVID-19 compliance. Physical distancing was, however, reported to be a difficult issue to control in a tightly-knit neighbourhood setting.

Scheduling appointments was an example of how both parties collaborated with designated roles.

HMs were requested to phone Hatzola to make appointments in advance (which was beneficial to people without internet access at home), and records were maintained by CCGs:

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Adopting this localised and collaborative approach indicated how the issues perceived by PH professionals to influence vaccination service delivery are not always a major problem in practice.

The involvement of Hatzola in local vaccination delivery was perceived by CRs and PH professionals as increasing trust in the national coronavirus vaccination programme. 'Our feedback from every community, not just the Orthodox community, is "I don't want to go trekking off to ExCeL, having to get on the bus or on the tube," so can't you come to me?' (PH3) PH professionals did, however, recognise that localised vaccination services offered particular benefits to encourage uptake among Haredi Jews. Haredi Jews were viewed by a PH professional . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted September 15, 2021. ; https://doi.org/10.1101/2021.09.10.21263372 doi: medRxiv preprint as a self-protective minority that felt uncomfortable 'integrating with others,' so Hatzola-hosted vaccination services were perceived as an 'Orthodox-friendly place to come' (PH3).

Participants were careful to note that Hatzola's involvement was not intended to replace the role of mainstream coronavirus vaccination sites, but rather to initiate awareness of -and 'normalise' The majority of Haredi Jewish constituents were then expected to attend general coronavirus vaccination sites for the first and/or second dose of the vaccine (with Hatzola maintaining a role in allocating vaccination appointments to general sites). As one local healthcare professional responded:

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The positions of these parents reflect how, in all populations, there will be a small proportion of people opposed to vaccination -which does not undermine the potential value of localised services for the wider population.

A wide range of stakeholders from the PH and CR research clusters were involved in promoting local coronavirus vaccination uptake through information and endorsement initiatives. Public relations campaigns decided to amplify the authority of Hatzola as a vehicle to mediate public trust:

'We decided not to engage in trying to convince people that conspiracies are not true. The very fact that we decided to put out adverts telling people to get vaccinated, that people saw Hatzola's logo, or Hatzola brand and Hatzola events, that in itself was a strong enough message for people to trust they can come and they can take the vaccine and that it's safe.' (CR7)

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Rabbinic and communal authorities implicitly and explicitly endorsed the Hatzola-hosted sessions and general coronavirus vaccination programme. It should be noted that to our knowledge no official mandate or ruling of Jewish law (psak halacha) was put forward by Haredi rabbinic authorities in the region under study, to the concern of some healthcare professionals involved in delivering the coronavirus vaccines:

'Rabbis felt it was a health matter and it was between the individuals and their own doctors to make the decisions. They did not feel that that was a halachic issue, that it was a medical issue within which they shouldn't interfere.' (CR8) Rather, rabbinic authorities took an approach of discussing the vaccine on a one-to-one basis with constituents, though it is important to note that senior Haredi rabbinic authorities were photographed being vaccinated as part of the PR work around the Hatzola events. For participants affiliated to particular Haredi movements with rabbinic leaders based in the USA or Israel, health decision-making was influenced by the guidance of local and international rabbis.

Situated concerns around coronavirus vaccines did arise at a household level, which PH and CR sought to address through local information campaigns. HMs commented on the circuitous flow and exchange of vaccine safety information from the US and Israel via WhatsApp groups.

Unsubstantiated claims that coronavirus vaccines could affect women's fertility were cited by HMs, which raised particular implications in a setting where larger family sizes are idealised:

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Other women were concerned by claims that coronavirus vaccinations could affect fertility, but ultimately 'put faith in the fact that it was safe' (HM10). PH workers had encountered concerns that the vaccines could affect fertility and were working to reassure younger age cohorts through Hence, promotion of a national vaccination campaign had to consider the situated issues that arose at local-levels.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The localised approach involved hosting a select number of Hatzola-led vaccination sessions to serve as a gateway for household members to be exposed to the national coronavirus vaccination programme in a space and service that was perceived as familiar, trusted and convenient.

Subsequently, household members could book vaccination appointments at local vaccination centres through Hatzola. The region under study is home to a diverse range of ethnic minorities, and like many London Boroughs, coronavirus vaccination coverage is lower than the national average. 33 The continued collaboration between public health professionals and Hatzola offers an opportunity for decision-makers to identify whether uptake remains suboptimal among Haredi Jews, whether additional Hatzola-hosted sessions are required, and how these could support the next phase of the national coronavirus vaccination programme.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Unlike past studies, 16 our data suggests that the coronavirus vaccination was valued for international travel. Yet, a minority of participants maintained, questions and concerns around vaccination safety, which were not addressed by the Hatzola-hosted sessions. The issue of refusal in a minority of participants likely reflected similar issues in achieving universal coronavirus vaccination coverage across the UK population, 2 which includes public concerns around safety. 34 While we did encounter misinformation about vaccinations in general, it is important to remember that coronavirus vaccines were developed and implemented at recordpace. Hence, it is not surprising that some household members cited concerns about the safety and long-term effects of new coronavirus vaccines.

Policy-makers have long considered public health collaboration with religious and communal authorities an important part of effective and sensitive vaccine delivery-strategies. 25 Moreover, the WHO TIP programme is premised on community engagement, which 'means including members of underserved population groups among active stakeholders who will define barriers to immunization and design solutions to overcome them.' 35 The UK coronavirus vaccine programme has since heralded innovative attempts to make vaccines more accessible for minority groups, evidenced by administering vaccines in 'pop-up' clinics in places of worship and community centres. 36 The model of localising vaccination that we outline builds on previous learning around issues of vaccine confidence, convenience and complacency by sharing responsibility for vaccine delivery with trusted community services.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Based on our analysis of a localised delivery of the UK coronavirus vaccination programme, we suggest there is a space to discuss complementary vaccination services to improve access to routine vaccinations among ethnic and religious minorities with a history of suboptimal coverage leading to outbreaks of preventable disease. A model of localised vaccination services does not mean overhauling vaccination services entirely, but identifying how gaps in service provision can be addressed in ways that involve trusted community organisations.

Localising vaccination services in ways that enable collaboration and coordinated delivery is a promising approach, which is not cost neutral. Challenges arise when funding is not allocated for localised services, but sustained investment may outweigh costs in minority settings that are susceptible to outbreaks of preventable disease. In the model of localised services that we discuss, a degree of responsibility over vaccine location, delivery and promotion is handed to partnering community organisations. Yet, collaboration with minority welfare groups requires considerable public health oversight. Our analysis suggests that public health services, local authorities and central government will need to maintain responsibility for assessing the suitability of partnering organisations to maintain public trust in vaccination, legalities of administration 37 24 vaccination programmes in ways that directly address the concerns of ethnic and religious minorities, as Hatzola did in the measles outbreaks described above. An implementation method is a more complicated operation, indicated by the scaled-up involvement of Hatzola in the UK coronavirus vaccine programme, and involves the following key considerations:

UK data has consistently suggested that ethnic and religious minorities are less likely to accept the new COVID-19 vaccinations. 2 This study interviewed a wide range of people, including public health professionals, community representatives and intended beneficiaries to examine opportunities to promote high coverage levels. We recognise that some stakeholders involved in delivering the coronavirus vaccination programme were unable to be recruited. Further work should consider how collaborative organisations perceive the feasibility of localised vaccination services as outlined above.

This study examined how a national vaccination campaign, the largest in British history, was localised in collaboration with welfare groups, which raises implications for subsequent coronavirus booster shots as well as the routine vaccination programmes. Localising vaccination services raises opportunities for greater vaccine equity by supporting ethnic and religious minorities to collaborate in safeguarding community health and wellbeing.

TC, MM and BK conceived of the study. BK and TC planned and conducted the qualitative data collection and led the data analysis. KG, ChR, RE, NS, LL, SMJ contributed to the design of the study. All authors reviewed the analysis and contributed to writing the manuscript.

This work was jointly funded by UKRI and NIHR [COV0335; MR/V027956/1], a donation from the LSHTM Alumni COVID-19 response fund, HDR UK, the MRC and the Wellcome Trust.

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We thank our study participants for their time and insights, and Dr William Waites for comments on an earlier draft.

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