key: cord-1039521-a50lcvre
authors: Kasstan, Ben; Mounier-Jack, Sandra; Letley, Louise; Gaskell, Katherine M.; Roberts, Chrissy H.; Stone, Neil R.H.; Lal, Sham; Eggo, Rosalind M.; Marks, Michael; Chantler, Tracey
title: Localising vaccination services: Qualitative insights on public health and minority group collaborations to co-deliver coronavirus vaccines
date: 2022-02-17
journal: Vaccine
DOI: 10.1016/j.vaccine.2022.02.056
sha: 3c6146406b2f41be37ac73bcf20c4a37fcdbc749
doc_id: 1039521
cord_uid: a50lcvre

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.

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 These events occurred alongside health system reforms that led to a fragmentation of vaccination services. 18 The present study focuses on attempts to optimise the UK COVID-19 vaccination programme (henceforth CVP) among Haredi Jews, who are often and problematically termed 'ultra-' or 'strictly Orthodox.' Haredi Judaism consists of diverse movements (sub-groups) that are distinguished by ethnicity and place of origin, and differences in customs and stringencies that influence social organisation and how religious law (halachah) is interpreted and practiced. Haredi Jews are selfprotective and carefully manage encounters with broader society, 19 which may raise implications for healthcare services. 20 Engagement with healthcare services should be understood within the respective national context of health systems, but also the global circulation of ideas and information in social networks than spans Europe, North America, and Israel. Jewish law does not explicitly endorse or prohibit vaccination, though rabbinic authorities have historically accepted vaccination as a safe way to protect child and population health. 21 Jewish law, however, is not always the primary influence on vaccine decision-making among Haredi parents. 13, 22 It should not be assumed that Orthodox and Haredi Jews will defer family health decisions to religious authorities. 20, 23 

Recent studies exploring CVP uptake among Haredi 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. 24 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 vaccinepreventable disease. Emerging directly from the data analysis in our study, we define localising vaccination services as collaborating with minority health organisations to deliver vaccines in ways that meet their situated (context-specific) needs and expectations.

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.' 25 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 might simultaneously promote confidence and remove barriers to accessing routine vaccination services and future CVPs.

Localising vaccination entails more than attempts to partner with religious and communal authorities, which are recommended in global health delivery strategies, 26 especially as part of mass vaccination programmes in the global south such as polio. 27, 28 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. Broader study objectives included examining: i) how COVID-19 information was shared with a Haredi Jewish minority, ii) what their perception of risk were and ii) their views of vaccination interventions aimed at containing the epidemic.

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. A key strand of the interviews focused on the involvement of 'Hatzola' in delivering the CVP. Hatzola (Hebrew: rescue) is a volunteer emergency medical service instituted by and for Haredi neighbourhoods around the world, that operates via local branches and is funded by the populations they serve. Hatzola personnel can communicate health information and respond to questions in vernacular languages (English, Yiddish), and most personnel in London wear uniforms and kippot (religious head covering for males)which distinguish them as forming part of the population they serve. 29 The London

Hatzola branch under study supported the local COVID-19 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. 30, 31 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 13,20 and TC's research examining barriers to accessing vaccination services. 16, 18 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) prepandemic collaborations to address issues in routine vaccination delivery; ii) scaling up collaborations during the CVP and division of responsibility; iii) benefits and limitations of a localised approach for minorities with historically suboptimal levels of vaccination coverage; iv) household concerns and responses to Hatzola-hosted COVID-19 vaccination sessions; and v) CVP information and responding to situated concerns. 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:

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 CVP 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-hosted vaccination sessions would take place in one of the designated and approved local vaccination centres, with a clear division of roles between Hatzola and PH bodies.

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 CVP. 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: As one local healthcare professional responded:

Localised vaccination services also involved flexibility when it came to who was eligible for vaccination, which, at the time these events took place (February 2021), 

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-toone 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 as well as the implementation of CVPs in those settings (which are characterised by different healthcare systems and models).

Situated concerns around COVID-19 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 COVID-19 vaccines could affect women's fertility were cited by HMs, which raised particular implications in a setting where larger family sizes are idealised:

'There are rabbonim in America not letting the girls do vaccines due to fertility issues.

So I don't know, at the moment, I wouldn't, due to fertility issues, give her [daughter] a vaccine yet, no, I definitely wouldn't.' (HM8) Other women were concerned by claims that COVID-19 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 targeted communications campaigns. 'We were asked time and time again, "if the prevalence rate was so high, aren't we all immune, don't we have herd immunity?" We've had to spend quite a lot of time explaining why that isn't the case.' (CR8)

Hence, promotion of a national vaccination campaign had to consider the situated issues that arose at local-levels.

Implementing a localised model of vaccination delivery enabled public health services to engage a self-protective religious and ethnic minority through a trusted care provider, which took an active role in communication, booking and hosting vaccination sessions in a designated clinic. Moreover, Hatzola was already involved in the local epidemic response by providing emergency care and public health messages. Localising vaccination services required flexibility in implementation to promote higher local coverage rates, which reflected practices observed in the national CVP -such as re-distributing doses to avoid waste. 33 Public health professionals reported that vaccination sessions were booked to capacity, indicating a measure of impact for this localised approach to delivery.

The localised approach involved hosting a select number of Hatzola-hosted vaccination sessions to serve as a gateway for household members to be exposed to the national CVP 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, COVID-19 vaccination coverage remains lower than the national average at the time of writing (January 2022). 34 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 Hatzolahosted sessions are required, and how these could support the national CVP as it continues to evolve.

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 COVID-19 vaccination coverage across the UK population, 2 which includes public concerns around safety. 35 While we did encounter misinformation about vaccinations in general, it is important to remember that COVID-19 vaccines were developed and implemented at record-pace. It will be important to continue monitoring public attitudes to vaccination to ensure health professionals are equipped to address concerns, at the same time it is essential not to make vaccine hesitancy concerns appear larger than they actually are. 36 Policy-makers have long considered public health collaboration with religious and communal authorities an important part of effective and sensitive vaccine deliverystrategies. 26 The UK CVP 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. 37, 38 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. While Hatzola is specific to the Haredi Jewish context, ethnic and religious minorities more broadly operate welfare services and support groups to address health inequities. 39, 40 The potential for volunteers to be trained as CVP vaccinators 41 means that the scope for collaborations between public health and minority welfare groups is extensive, though the suitability of collaborating welfare groups (and funding arrangements) will need to be assessed by local authorities.

Based on our analysis of a localised delivery of the UK CVP, 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. It is also important to note that the re-structuring of public health and vaccination services in England has raised long-running implications for the delivery of routine immunisation programmes, and which causes and compounds gaps in coverage. 18 There is a need to address these issues in vaccination delivery across the board, while also devising creative strategies to collaborate with minority populations to address persistent outbreaks of preventable diseases. The latter approach has gained more traction during the COVID-19 pandemic, which has provoked government responsiveness to the contribution health inequalities make to morbidity and mortality.

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 41 and accurate data recording, procurement of vaccinations, purchasing, cold storage, oversight/accountability of collaborative groups, signposting sites for reporting suspected side effects for reporting suspected side effects (e.g. United Kingdom: Yellow Card: USA: Vaccine Adverse Event Reporting System).

Future localisation of vaccination services could take two key approaches of collaboration via communication or implementation strategies. A communicationsonly focus could promote state 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 CVP, and involves the key considerations depicted in Figure 1 . The involvement of outside agencies in this way will have implications for commissioning, supervision and training and monitoring, but the potential advantages for local public health infrastructures could outweigh these 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 CVP 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 COVID-19 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, CR, 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. This research was supported by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Immunisation.

Ethical approval to conduct this study was granted by The London School of Hygiene and Tropical Medicine Research Ethics Committee (Ref: 22532).

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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

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

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

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.