Tailoring Immunisation Programmes: Using Behavioural Insights to Identify Barriers and Enablers to Childhood Immunisations in a Jewish Community in London, UK

"The comprehensive stakeholder engagement which is a key pillar of the TIP approach ensured a deeper understanding of the barriers and enablers to vaccination as well as increasing ownership in the community."

In 2014, in consultation with the community, the teams responsible for immunisation services in the London, United Kingdom (UK) borough of Hackney decided to use the World Health Organization (WHO) Tailoring Immunization Programmes (TIP) approach to fully explore the reasons for sub-optimal vaccination uptake within the Charedi Orthodox Jewish community. This paper details how the use of behavioural insights enabled the categorisation of subgroups, the diagnosis of supply- and demand-side barriers and enablers to vaccination, and the development of evidence-informed responses to improve vaccination coverage and prevent disease outbreaks.

In 2011, in response to increasing numbers of people refusing or delaying immunisation within the European Region, the European Technical Advisory Group of Experts on Immunisation (ETAGE) asked the WHO Regional Office for Europe to develop tools to help countries address vaccine hesitancy. This resulted in the development of the TIP approach, as outlined within a guide, published in 2013. (See Related Summaries, below.) In brief, the approach, which has been used in various contexts, involves working closely with a broad stakeholder group, particularly the communities involved, to identify their beliefs, experiences, requirements, and preferences.

Analysis of surveillance and outbreak data confirmed that uptake of immunisations was lower within the Hackney Charedi community and that recurring vaccine-preventable diseases (VPDs) were placing a burden on the community, particularly in children under 4 years of age. In response, a TIP initiative was carried out in 2015/16 by representatives from Public Health England (PHE), National Health Service England (NHSE), with support from WHO Regional Office for Europe.

• An initial meeting served to engage key stakeholders, such as a local rabbi, who agreed on the focus of the TIP process in the community. The meeting led to: (i) mapping of the current immunisation service and support for immunisation within the community; (ii) a literature review conducted to build on evidence from research with Charedi communities globally; and (iii) analysis of relevant surveillance and outbreak data.
• A second meeting enabled broader stakeholder engagement, including community representatives from 3 local children's centres, the health policy lead for the umbrella organisation for Orthodox Jewish charities and voluntary organisations, and local health and immunisation service providers. An initial situation analysis was presented, and a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was carried out in order to identify barriers and enablers to immunisation. A questionnaire was designed to address key issues identified in this SWOT and was distributed to 126 parents via general practices (GPs) and children's centres; Hebrew and Yiddish translations were available.
• Semi-structured interviews were carried out with 10 parents and 10 key informants, including community leaders, commissioners, and providers of immunisation services, to explore the barriers and enablers identified in the questionnaire in more detail (see Table 1).
• Issues were grouped according to whether they were societal, community, or individual, and parents were grouped according to their beliefs and behaviours to ensure solutions could be tailored to meet the needs of different segments of the community.

The results of the formative research and behavioural analysis are shared in the paper. In short, the results challenged the assumption that a cultural or religious anti-vaccination sentiment existed within the community. Where mothers were choosing to delay or refuse vaccinations, their reasons were broadly similar to the wider population (e.g., concerns over side effects). Critical issues related to access to and convenience of immunisation services. In addition, the researchers learned that there are unmet information needs within the community; community-specific information was particularly valued.

A feedback meeting was held with community members, a senior rabbi, NHS commissioners and providers, GP staff, PHE and WHO representatives, government officials, and the qualitative research team from the London School of Hygiene & Tropical Medicine to discuss the findings and to provide input into the grouping of the mothers, who were found to generally make vaccination decisions, into 4 broad categories (see Table 2). For example, there are barriers and enables specific to the mother who is sceptical of health authorities, as well as specific actions that could be tailored to reach her, such as providing cultural sensitivity training to all staff at health facilities to support their creating positive moments for mothers and their children.

This feedback meeting also enabled a series of recommendations for commissioners and providers of immunisation services working with the community to be developed. For example, it was found that services should be flexible, sustainable, and feature the use of community champions or Chaedi immunisation nurse specialists. Continued close working with community members, including religious leadership, and use of community media to publicise immunisation information could help to promote immunisation as a social norm (e.g., through messaging such as "most people within the community get their children immunised on time"). As part of the way forward, it is recommended that all community-specific interventions are fully evaluated so that effective, sustainable solutions can continue to be developed and refined.

In short, the paper found the TIP approach to be an effective way of investigating factors linked to sub-optimal immunisation within the Charedi community.

Click here for a 92-page PHE report on this TIP experience.