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Abstract
Objectives This study explored vaccination attitudes and behaviours among Polish and Romanian communities, and related access to primary healthcare services.
Design A qualitative study using in-depth semistructured interviews with Polish and Romanian community members (CMs) and healthcare workers (HCWs) involved in vaccination in areas with large Polish and Romanian communities. CMs discussed their vaccination attitudes and their experiences of accessing vaccinations in England. HCWs shared their experiences in vaccinating Polish and Romanian communities.
Setting Recruitment focused on three geographical areas in England with large Polish and Romanian populations (in London, Lincolnshire and Berkshire).
Participants 20 Polish and 10 Romanian CMs, and 20 HCWs. Most CMs were mothers or pregnant women and were recruited from London or Lincolnshire. HCWs included practice nurses, health visitors and school nurses recruited from the targeted geographical areas.
Results Although most CMs reported vaccinating according to the UK schedule, obstacles to vaccination were highlighted. CMs experienced difficulties navigating and trusting the English primary healthcare system, and challenges in accessing credible vaccination information in Polish and Romanian. CM vaccination expectations, largely built on knowledge and experiences from Poland and Romania, were often unmet. This was driven by differences in vaccination scheduling and service provision in England, such as nurses delivering vaccines instead of doctors. CMs reported lower acceptance of the influenza vaccine, largely due to perceptions around the importance and efficacy of this vaccine. HCWs reported challenges translating and understanding vaccination histories, overcoming verbal communication barriers and ensuring vaccination schedule completeness among families travelling between England and Poland or Romania.
Conclusions This study identified vaccination uptake and delivery issues and recommendations for improvement. HCWs should discuss health service expectations, highlight differences in vaccination scheduling and delivery between countries, and promote greater understanding of the English primary healthcare system in order to encourage vaccination in these communities.
- qualitative research
- primary care
- public health
- vaccination
- polish and romanian communities
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Strengths and limitations of this study
As the first study to explore vaccination attitudes and behaviours among Polish and Romanian communities in England, this research has highlighted key factors affecting vaccination uptake among these communities and how these can be addressed.
Conducting interviews with community members and health workers allowed for the exploration of barriers to both vaccination uptake and delivery.
Due to challenges in recruiting community members, the study was advertised via social media and our recruitment expanded beyond our targeted geographical areas. Several comments received via social media on Romanian pages appeared to reflect a mistrust in taking part in research and some antivaccination sentiments.
The study may not have captured vaccination behaviours that are particularly reflective of recent migrants. Our community member participants were generally well linked with health services and had good English language skills. Users of social media may also not be particularly representative.
Introduction
Protecting populations against vaccine-preventable diseases require immunisation programmes to achieve high vaccination coverage. The measles outbreaks that affected over 20 000 people and resulted in 35 fatalities in Europe between 2016 and 20171 2 are a reminder of the consequences of failing to achieve this. To optimise vaccination coverage and protect populations against vaccine-preventable diseases, it is essential for healthcare workers (HCWs) and vaccination programme managers to understand and address barriers to vaccine uptake within specific populations. Migration is a recognised risk factor for undervaccination,3 with factors such as cultural and language barriers, and unfamiliarity with destination country health systems, hindering vaccination access.3 4 This potentially leaves migrant populations vulnerable to vaccine-preventable diseases.5
Since the expansion of the European Union (EU) to include the EU8 countries (Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia) in 2004, and EU2 countries (Romania and Bulgaria) in 2007, the Eastern European (EE) born population in the UK has consistently increased6 (figure 1). In 2017, Polish and Romanian were the most common non-British nationalities in the UK.6
Estimated number of EU8 and EU2 born residents in the UK, 2004 to 2017. Data extracted from the Office for National Statistics.6 Data for each year are from January to December. EU, European Union.
Despite the sizeable Polish and Romanian population in the UK, there is limited evidence about vaccination uptake in these communities.7 In England, as well as other European countries, a barrier to health research involving EE communities is the lack of a systematic way to identify such individuals in health-related datasets. Where vaccination uptake has been explored by ethnicity, a concept often linked to migrant status,8 this has largely included broad ethnic categories (eg, ‘white other’) and not specific nationalities or countries of birth.9–12 One traveller study specifically explored vaccination uptake among Romanians that also identify as Roma,13 a distinct ethnic and cultural group that have experienced extensive discrimination, persecution and marginalisation across Europe. This traveller study highlighted that among Roma participants language and literacy were particular barriers to accessing vaccines and health services.13
To our knowledge, no research has specifically focused on vaccine-related attitudes and behaviours among Polish and Romanian communities in England. This is despite differences in vaccination schedules2 14 (table 1), vaccination coverage15 (table 2) and vaccine confidence between countries.16 Notable differences in scheduling include the lack of health system funding for influenza and rotavirus vaccination in Poland and Romania, in comparison to the UK (table 1). Also, in contrast to the UK and Romania, 11 childhood vaccinations in Poland are mandatory, with vaccination refusal leading to monetary fines (table 1). There are also differences in vaccination coverage, which is notably much lower in Romania, compared with the UK and Poland (table 2). Coverage with two doses of measles vaccine is particularly low in the UK (88%), and dangerously low in Romania (75%) (table 2).
Comparison of childhood and adult vaccination schedules in Poland, Romania and the UK2 14
WHO-UNICEF estimates of vaccination coverage (%) in Poland, Romania and the UK in 201715
This study explored vaccination attitudes and behaviours among Polish and Romanian community members (CMs) in England, and related access to primary healthcare (PHC).
Methods
Theoretical framework
The Social Ecological Model (SEM) was adopted as a theoretical framework to underpin this study and guide the identification of factors affecting vaccination uptake, and areas for focusing policy and practice recommendations.17 The SEM acknowledges that health behaviours, such as vaccination uptake, are shaped by multiple factors at the following levels: intrapersonal/individual (eg, knowledge, attitudes), interpersonal (eg, family, friends), institutional (eg, workplaces), community (eg, neighbourhoods, community groups, local organisations) and policy (eg, laws, national or local policies).17 The SEM has previously been used in the context of vaccination behaviours.18–20 Using the SEM helped to identify areas in which to target improvement efforts.
Recruitment and data collection
We conducted in-depth semistructured interviews with Polish and Romanian CMs and HCWs involved in the provision and delivery of vaccinations in areas with high Polish and Romanian populations. Recruitment focused on three geographical areas (Boston, Lincolnshire; Slough, Berkshire; Brent, London), with different levels of vaccination coverage and large EE populations.6 21 We aimed to interview approximately 20 Polish and 20 Romanian CMs, and 20 healthcare providers. This number of participants was considered achievable, given practical considerations, and adequate to gain insight into the topic.
CMs were identified through community venues (including schools, nurseries and churches), and advertisements in Polish newspapers, EE shops and via Twitter and Facebook pages. Eligible Polish and Romanian CMs included parents and grandparents and men and women belonging to the target groups for influenza vaccine (pregnant women, adults aged 65+years and people with specified long term conditions such as diabetes or heart disease). CMs were compensated with a £10 gift voucher. We identified HCWs via general practices and community providers. Potential participants were given an information sheet, fully detailing the study objectives and explaining all aspects of participation, including the right to withdraw from the research.
Participants were interviewed in person or via telephone. CMs were offered the option of being interviewed in English, Polish or Romanian. Interviews were audio recorded and reflective notes were taken during interviews. Face-to-face interviews were conducted with CMs in community venues (eg, libraries and quiet coffee shops) in a location convenient for the participant. Face-to-face interviews with HCWs were performed in workplaces, in quiet environments away from clinical areas. Most interviews with CMs lasted 30–60 min, and approximately 20–40 min with HCWs.
CMs were asked about their vaccination and related PHC experiences. HCWs were interviewed about vaccination service delivery to Polish and Romanian service users. CMs and HCWs were solicited for service improvement suggestions. Interview topic guides were developed for this study with community involvement.
Public involvement
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. This involvement aimed to increase the relevance and usefulness of the study and help to promote study recruitment.
Data analysis
Interviews were transcribed verbatim and analysed thematically using the stages outlined by Braun and Clarke22: data familiarisation, coding and theme identification and refinement. To enhance the rigour of the analysis, coding approaches and data interpretations were discussed between SB, MZ and SM-J.
Interviews were coded using initial codes generated from the interview topic guide and levels of the SEM. Use of the SEM helped to identify where to focus policy and practice recommendations.17
Research team and reflexivity
This research was led by SB, a postdoctoral researcher at the London School of Hygiene & Tropical Medicine (LSHTM). The researchers had no connection with the research participants prior to commencing the study. SB had a clinical background, having worked as a nurse in haematology and oncology. The team had academic research (SB, MZ, ME, MR, SM-J) and clinical or public health backgrounds (SB, ME and MR). SB, SM-J and MZ were based at LSHTM at the time of the study, and ME and MR at Public Health England (PHE). SB, ME, MR and SM-J conducted this study as part of the Health Protection Research Unit in Immunisation, a collaboration between LSHTM and PHE.
Findings
Participants
Twenty Polish and 10 Romanian CMs and 20 HCWs were interviewed (table 3). Three interviews were conducted in Polish by MZ and the remaining interviews were performed by SB in English (n: 27). Detailed CM characteristics are outlined in online supplementary table 1. Most CMs were mothers or pregnant women (n: 27). In addition, two Romanian fathers and one Polish woman eligible for the influenza vaccine participated. The average time spent living in the UK was 11 years for Polish CMs and 9 years for Romanian CMs. CMs were recruited via social media (n: 22), a Polish newspaper (n: 2), a community group (n: 1), a children’s club (n: 1) and through word of mouth (n: 4). The use of social media meant that recruitment was not geographically restricted, most CMs were recruited from London or Lincolnshire.
Supplemental material
Healthcare worker and community member participants
One HCW was recruited from an area not originally targeted for recruitment (table 3) because of strong experience in working with EE communities. In addition to National Health Service (NHS) HCWs, we also recruited a vaccination advisor (HCW#17) who led an online Romanian vaccination forum organised by medical professionals.
Despite advertising the study extensively, there were challenges in recruiting CMs and recruitment expanded beyond our targeted geographical areas. We had intended to recruit more Romanian CMs, to match the number of Polish participants; however, this was not possible during the timeframe of the study due to challenges with recruitment. 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, antivaccination attitudes23 24 and concerns around living in England following the Brexit vote.25
No repeat interviews were performed, and no participants withdrew from the study.
Factors affecting vaccine uptake, delivery and PHC access
CMs mostly reported accepting vaccines according to the UK schedule, although the influenza vaccine was more often declined (online supplementary table S1). CMs reported struggling with the vaccination decision-making process, which involved the evaluation of perceived potential benefits and risks.
We present factors affecting vaccine uptake and delivery as identified by CMs and HCWs under seven main themes: (1) challenges to navigating the health system, (2) transnational use of health services, (3) language and literacy, (4) expectations of vaccination delivery, (5) vaccine acceptance, (6) vaccine accessibility and (7) trust. These themes span each level of the SEM. Wider barriers to service access were also highlighted in relation to PHC, which has potential implications for vaccination delivery as vaccines are mainly administered in this setting. There were no noticeable differences in the themes that emerged between the interviews conducted in Polish and English.
Challenges to navigating the health system
CMs reported institutional level difficulties in navigating the health system. Several CMs reported challenges in registering with general practices due to uncertainties around entitlement to care and difficulties in producing proof of address as requested by some practices. Interpersonal relationships were a source of support in navigating the health system, with several CMs reporting their involvement in helping Polish and Romanian family members and friends to register with general practitioner (GP) practices.
CMs perceived the English PHC system as markedly different to systems in Poland and Romania. CMs explained that in Poland and Romania service users would more often directly access specialist pay-for-services, bypassing GPs. At an intrapersonal level, PHC in England was frequently viewed as a hindering process instituted to restrict access to secondary care and cut costs.
….in Poland a GP is a GP and they accept the fact that they are GPs….so if they cannot deal with something, they will very easily refer you somewhere else…. If you feel dizzy or you’ve got a headache, they will send you to a neurologist. It’s not a problem. Here, trying to get a referral somewhere is just like God help you. (CM#10—Polish mother, Cornwall)
The most critical reports of primary care were made by CMs that had experienced particularly long delays in accessing treatment in England and had quickly accessed treatment on presentation to services in Poland and Romania.
Transnational use of health services
CMs often reported ongoing use of health services in Poland and Romania; in some instances, this was done to avoid relying on PHC in England to gain direct access to secondary care. CM families were also reported to travel to Poland or Romania prior to or in the weeks following the birth of a newborn, to see family and receive healthcare. Some families vaccinated their children during these visits due to the timing of their travel.
Vaccinating children in more than one country could cause disruption of the UK immunisation schedule. At an institutional level, HCWs faced challenges in determining which vaccines had been administered to the child, with many returning to England with undocumented vaccination histories. Polish participants also suggested that some families prefer to access certain vaccinations in Poland, an intrapersonal level decision that was influenced by cost, a policy level influence, in some instances.
…. there were some vaccinations we did in Poland because it was cheaper, like chicken pox for [our daughter] …. I think it was £100 here or something like that. I think we paid half in Poland…. we managed to get it when we were on holiday.’(CM#18—Polish mother; Lincolnshire)
Language and literacy
Communication barriers during PHC consultations were reported by both HCWs and CMs. The latter particularly struggled with HCW use of medical terminology and jargon, and the inability of health services to provide information in languages other than English. These factors fall within the institutional level of the SEM. 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.
Similarly, HCWs struggled to translate vaccination histories. This was a time-consuming process and one, as HCWs suggested, which would be better completed by an alternative service prior to attendance at the practice. Some HCWs reported relying on colleagues with Polish or Romanian language skills, including multilingual receptionists, to translate documents. 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.
Expectations of vaccination delivery
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 (table 1), HCW roles and interactions in vaccination appointments.
Comparison of vaccination programmes in the UK, Poland and Romania
Both CMs and HCWs noted that existing variations in vaccines and scheduling between national programmes led to uncertainties. For example, confusion arose for hepatitis B vaccine, which has been widely available in Europe but was only recently introduced routinely in the UK,26 and BCG vaccination that is not universally offered in the UK.27 Polish parents reported unease at not receiving the BCG vaccination for their children, as Poland is not classed by PHE as having a high TB prevalence.28
The number of childhood vaccinations administered within a short space of time was also reported as a concern by parents. Some CMs argued that in Poland and Romania some vaccines could be available with a choice of formulations, such as measles, mumps and rubella (MMR) either freely as three separate jabs or for a fee in one jab, while the NHS only administered the combined three-dose MMR vaccine. Similarly, choice was also provided in Poland and Romania between vaccine brands, although at a cost when administered by private providers. Branded vaccinations were reportedly portrayed as better.
…the GP [In Romania] told us, ‘just use this one.’ I think [the GP] might have told us, ‘If you want,’ ‘you know, I can give you this standard free of charge one. If you want your real one, you just go to the pharmacy, buy it, bring it, we’ll do it, off you go’. (CM#4—Romanian father, Maidenhead)
Difference in consent for vaccines in schools was highlighted between England and Romania by one HCW. It was reported that providing written consent in England could be off putting to parents not used to this particularly formalised approach, which made vaccinations appear riskier.
Vaccine administration
Polish participants discussed that in Poland vaccines are administered by doctors, while in England this role is performed by nurses. Some Polish participants were concerned that nurses in England might not be qualified for this role. Polish mothers also highlighted concerns that children were not given a physical examination before vaccine administration. Instead, it was reported that the onus on whether vaccinations should be given was placed on the parent, who was asked whether their child was healthy.
I do not like it, for example, that children are not tested (checked) before vaccination. [The decision to give the vaccination] depends on the parent’s opinion whether the child is healthy or not, but it is sometimes difficult to really judge whether a child is healthy, if he or she goes with a cold, or I do not know, with something. (CM#12—Polish mother, Wellingborough)
One Polish parent also reported that children attending vaccination services in Poland would wait in a separate area to symptomatic patients. The absence of segregated areas between healthy and sick patients in GP practices in England was found to be alarming.
Vaccine acceptance
Although most CMs regarded vaccines as essential for protection against disease, certain vaccines created greater concern or were considered less important than others. Several participants voiced higher apprehension around ‘newer’ vaccines that were considered not to have been in use for enough time to be considered safe. Both MMR and the influenza vaccines were either considered unimportant or generated particular concerns. The hesitancy related to MMR was linked to the Wakefield controversy,29 but was reported not to be at any greater level than in the general population. Influenza was the dominant vaccine that CMs reported refusing (online supplementary table S1). Refusals were mainly based on the perception that this vaccine is unnecessary or not as important as other vaccines. Influenza was considered less serious compared with other vaccine-preventable diseases.
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.
Accessibility of vaccines
Appointment booking and appointment length
CMs reported that it was straightforward and easy to book vaccination appointments at GP practices; however, dissatisfaction was often noted around the time allocated. Similarly, HCWs considered it generally difficult to provide vaccine information, administer vaccines and document vaccine delivery within the time allotted (approximately 10–15 min), and this was made even more challenging because of communication barriers.
The time restriction on appointments made some CMs feel rushed and not listened to, potentially leaving them with questions and vaccine concerns that were not addressed. Interviewees reported that this could generate tensions.
Vaccination reminders
Although vaccination acceptance was high, HCW reported that attendance dwindled for EE children after vaccinations at 8 and 12 weeks.
CMs reported not always receiving vaccination reminders. There was a lack of consistency in the approaches used by practices in delivering vaccination recalls and the onus appeared to be primarily on the parents to book and remember appointments. Given the frequent travel of Polish and Romanian families to their home countries, appointments were easily missed.
Trust
‘Social’ trust in institutions and ‘interpersonal’ trust in individuals, terms used by Mechanic and Schlesinger,30 can be applied to underpin confidence in vaccines, vaccine delivery and health services. 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. Some CMs were particularly sceptical about the quality of healthcare in England:
I have more confidence in the doctor in Poland. Doctors in Poland are trained doctors. They study medicine for several years….Here, I have the impression that a doctor….they have everything on the computer. He’s typing in a computer that you come, have a cold, a fever, and [it] jumps out [from the computer], what he has to give me. (CM#12—Polish mother, Wellingborough)
Lack of trust in PHC was a driving factor for people opting to access emergency services in England and for seeking care in Poland and Romania or private Polish doctors in England.
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 (eg, 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 well-written unregulated sources that appear using Google searches, through parent forums, and on social media. These fall within the SEM as community level influences. Although as noted some CMs were not confident in HCWs, most CMs trusted HCWs advice on vaccines and the literature sources produced by the NHS on vaccinations influence at an institutional level, which was considered more credible than other sources.
Discussion
We found that vaccination attitudes and behaviours among CMs were influenced by multiple interconnected factors. These included language barriers, perceptions about vaccine safety and importance, and expectations around vaccination services and PHC.
Overall, the reported influence of language barriers, population transiency, negative perceptions of healthcare professionals, poor understanding of healthcare entitlements, work-life demands and lack of integration on PHC experience were consistent with the literature.31–39 Previous research also highlights that migrants may prefer to access health services in their country of origin due to negative perceptions of the English PHC system35 and greater confidence familiarity and confidence in their country of origin’s doctors.37 40
We found that vaccination and healthcare experiences in Poland and Romania shaped expectations of services in England. Differences in service provision in England, such as vaccine delivery by nurses, were met with uncertainty and anxiety. The variations in vaccination schedules across countries which caused concern among our participants are likely to affect migrant populations in other countries.
Influenza vaccination was commonly refused due to perceptions around its importance and efficacy. It is not clear whether influenza vaccination refusal is more prominent among Polish and Romanian communities. This warrants further exploration, particularly as confidence in vaccines has been decreasing in many European countries, most notably in Poland.16
We have identified key recommendations intended to improve vaccination and health service access by Polish and Romanian communities (table 4), many of which would be transferable to other European countries where these communities have also settled. While some of these recommendations incur additional staff time and costs, they should be placed in the broader context of ensuring high uptake and reducing the likelihood of disease outbreaks in these communities.
Key recommendations linked to study findings and levels of the Social Ecological Model
Conclusion
Overall, CMs reported accepting vaccination; however, several barriers to uptake were identified. These included difficulties in navigating and trusting the English health system, language barriers and challenges in accessing credible vaccine information in translated forms. Concerns around vaccine importance and efficacy were raised by CMs for influenza vaccine, which led to lower acceptance.
HCWs reported difficulties in translating and understanding vaccination histories, ensuring vaccination schedule completeness among families frequently travelling between England and Poland or Romania, and overcoming verbal communication barriers.
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 to discuss vaccination and health service expectations. Crucially, providers are recommended to routinely obtain and record vaccination histories, explain differences in vaccination delivery and scheduling, and consider vaccine schedule travel disruptions.
Acknowledgments
The authors would like to thank the research participants and members of the public involvement group. They thank Vanessa Saliba for providing helpful feedback and sharing her expertise during the project.
References
Footnotes
Funding The research was funded by the National Institute for Health Research Health Protection Research Unit in Immunisation at the London School of Hygiene & Tropical Medicine in partnership with Public Health England.
Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England.
Competing interests None declared.
Ethics approval The study received ethical approval from the London School of Hygiene and Tropical Medicine Observational Research Ethics Committee (Ref: 12124), the Health Research Authority (Project ID: 224734), and from Research and Development departments in the recruitment areas. Written informed consent was obtained from all study participants.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Patient consent for publication Not required.