'I Don't Think Anybody Explained to Me How It Works': Qualitative Study Exploring Vaccination and Primary Health Service Access and Uptake Amongst Polish and Romanian Communities in England

"In a context where external and internal migration has been growing in England and across Europe, and several measles outbreaks have occurred over the past few years, it is important that HCWs promote an open dialogue with service users..."

Migration is a recognised risk factor for undervaccination, with factors such as cultural and language barriers and unfamiliarity with destination country health systems hindering vaccination access. Despite the sizeable Polish and Romanian population in the United Kingdom (UK), there is limited evidence about vaccination uptake in these communities. This study explored vaccination attitudes and behaviours among Polish and Romanian community members (CMs), and related access to primary healthcare (PHC) services.

The Social Ecological Model (SEM) was adopted as a theoretical framework to underpin this study. The SEM acknowledges that health behaviours, such as vaccination uptake, are shaped by multiple factors at the following levels: intrapersonal/individual (e.g., knowledge, attitudes), interpersonal (e.g., family, friends), institutional (e.g., workplaces), community (e.g., neighbourhoods, community groups, local organisations), and policy (e.g., laws, national or local policies).

Recruitment focused on 3 geographical areas in England with large Polish and Romanian populations. A Polish community group was involved in the development of study documents, including the topic guides, and was asked to provide feedback on recruitment strategies. The study received some negative responses when advertised via social media on Romanian pages that appeared to reflect a mistrust in taking part in research and some anti-vaccination beliefs.

Participants in the in-depth semistructured interviews included 20 Polish and 10 Romanian CMs, and 20 healthcare workers (HCWs). Most CMs were mothers or pregnant women; HCWs included practice nurses, health visitors, and school nurses.

CMs mostly reported accepting vaccines according to the UK schedule, although the influenza vaccine was more often declined. CMs reported struggling with the vaccination decision-making process, which involved the evaluation of perceived potential benefits and risks. They also experienced difficulties navigating and trusting the English PHC system, as well as challenges in accessing credible vaccination information in Polish and Romanian.

To elaborate on the latter communication difficulties:

• CMs reported struggling with HCW use of medical terminology and jargon. To overcome language barriers, several HCWs reported using online translation tools to aide communication. HCWs considered that more "formal" modes of communication such as telephone or face-to-face interpreting services were difficult to organise, felt impersonal, and created greater uncertainties around messages becoming lost in translation. HCWs also struggled to translate vaccination histories. In some instances, practices had developed vaccine "crib sheets", providing the names of vaccinations in Polish and Romanian to help during consultations.
• Most CMs reported that they were not offered, or directed towards, vaccination and broader health information in their native language. CMs and HCWs recommended that vaccination information be made available in different languages, but there was recognition that cost could be a barrier. An additional challenge in working with Roma Romanian communities was overcoming literacy barriers. With those groups, HCWs found that face-to-face verbal communication, involving interpreters, was the best approach.

Furthermore, without a prior understanding of vaccination delivery in England, CMs based their expectations on intrapersonal knowledge and experiences in Poland and Romania. This meant their expectations were often unmet because of policy and institutional level differences in vaccination programmes, HCW roles, and interactions in vaccination appointments.

Although most CMs regarded vaccines as essential for protection against disease, several voiced higher apprehension around "newer" vaccines, and both measles, mumps, and rubella (MMR) and the influenza vaccines were either considered unimportant or generated particular concerns. The hesitancy related to MMR was linked to the Wakefield controversy, but it was reported not to be at any greater level than in the general population. Influenza was considered less serious compared with other vaccine-preventable diseases (VPDs); it did not appear that messages surrounding the larger societal benefits of influenza vaccination had been received. Several CMs also reported concerns that having the influenza vaccine could cause influenza-like side effects.

CMs discussed trust in relation to health authorities, the pharmaceutical industry, and HCWs. Trust in healthcare was partially shaped by different expectations of health services and a lack of understanding of how the English PHC system works.

• To promote trust in health services, it was considered crucial for HCWs to explain the system to service users. With some communities, HCWs reported that engagement was more effective using outreach strategies (e.g., door knocking, approaching community groups) rather than trying to encourage health service attendance.
• To develop trust in vaccines, it was considered important for CMs to be able to access credible information. CMs reported challenges in accessing and sourcing trustworthy vaccination information, amidst a barrage of unregulated sources that appear using Google searches, through parent forums, and on social media. Although some CMs were not confident in HCWs, most CMs trusted HCWs' advice on vaccines and the literature sources produced by the National Health Service (NHS) on vaccinations influence at an institutional level, which was considered more credible than other sources.

This study identified vaccination uptake and delivery issues and key recommendations intended to improve vaccination and health service access by Polish and Romanian communities (see table 4), many of which could be transferable to other European countries where these communities have also settled.

In short, the researchers indicate that HCWs should discuss health service expectations, highlight differences in vaccination scheduling and delivery between countries, and promote greater understanding of the English PHC system in order to encourage vaccination in these communities.