Ealing: Improving vaccine uptake across the borough

Ealing is the fourth largest London borough. It is situated in the north west of the city and has a diverse population. In mid-2021, vaccination rates were significantly lower than the London average. However, by mid-2022 vaccination rates were in line with the London average.

Crucially, uptake increased significantly in groups associated with low uptake such as low-socio economic groups and Black Caribbean and Pakistani communities. This case study showcases the community participation and engagement strategies used to increase vaccination rates in the borough. It is based on reflections by members of Ealing Council’s COVID-19 Vaccine Working Group and the results of a rapid evidence review produced by the Social Science in Humanitarian Action Platform.

In Ealing, the roll out of the COVID-19 vaccination programme was led by the NHS and supported by the local council. Initially, vaccination delivery was across two mass vaccination sites and a small number of GP surgeries. As the pandemic progressed Ealing Council’s COVID-19 Vaccine Working Group (VWG) became more agile in its decision making and activities.

The group analysed data on vaccine uptake across the borough and anecdotal feedback from vaccinators, health colleagues and the community which was then used to plan and adapt activities. Group members valued this collaborative working and credited it with improving response rates over time.

As the programme progressed it became apparent that people from low socio-economic groups and some ethnic minority backgrounds, (particularly people from our black and mixed ethnic background communities) had lower rates of vaccine uptake.

Strategies were developed to engage different communities including interactive public webinars such as an online event with a Somali group with a Somali Islamic scholar. There was some reluctance within the VWG to support the approach due to the relatively small number of individuals it would engage but the value of these events was later recognised.

A key lesson learned was that it may often be necessary to spend a greater proportion of resources on reaching smaller numbers of particularly disadvantaged and/or sceptical or hesitant people and groups. VWG members emphasised that this should be recognised as necessary and critical for equity and an overall effective vaccination response, as well as being relevant for addressing other public health priorities.

Community engagement was undertaken with residents, community groups, faith leaders and others with existing relationships to the council’s established community engagement team. Visits were also made to vaccination sites to speak to various groups. Although often ad hoc, these engagements gave VWG members a greater sense of community perceptions and needs. Transportation services to vaccination sites were also set up to support people who faced travel-related challenges.

A regional level weekly ‘huddle’ to improve vaccine equity hosted by the Northwest London Health and Care Partnership was also established, where learning across boroughs could be shared between council, NHS and community representatives.

Challenging narratives emerged. The question ‘why now?’ was posed by a young Afro-Caribbean woman who described the scepticism amongst some members of her community and other disadvantaged groups in the region. Many in these groups may feel reasonably suspicious of authorities’ sudden interest in their uptake of a vaccine when they may have otherwise felt their wellbeing has at best been ignored, and at worst, actively undermined by authorities.

To make vaccination more accessible, comfortable, and convenient, pop-up sites in various locations including faith centres, schools, and supermarket parking lots were established. Initial reluctance to this was overcome as significantly greater numbers of people arrived for vaccination at the first site than originally anticipated.

Clearer communications were developed to reassure people they would not have to give their personal details to get vaccinated. Consequently, many unregistered people, including undocumented migrants were vaccinated. Information was also translated into relevant languages in the borough through mobilisation of various community-based networks.

Overall, action for improving vaccine equity was undertaken through collaboration between the council, NHS and community partners. Each played key roles and learned lessons over time. This led to narrowing gaps in vaccine uptake between different social groups. Such gaps remain however, meaning that trust must be built with these communities.

Recently, the council has been awarded funding to set up a Community Champions programme to facilitate further community engagement, including closer working with residents and trusted community organisations to support vaccine uptake, and to address other issues of health inequity – many of which, are affected by similar issues of structural disadvantage and limited trust.

A first category of challenges relates to issues of fear and trust.

• Fear over vaccine safety
• Fear of vaccines linked to mistrust
• Mistrust due to exclusion and abandonment
• Fear of incrimination or deportation on the part of undocumented migrants.
• Information delays
• Assumptions about what community leaders and groups engaged by local authorities to promote vaccination are trusted by residents
• Diasporic links to leaders, networks, and institutions of countries of origin were also mentioned as influencing uptake among members of some communities.

Supply-side issues also impacted the accessibility of vaccines. These included:

• Short-lived GP engagement
• Uneven coverage across the borough
• Timing of vaccination availability
• The lack of appropriate and affordable transportation options
• A focus on overall numerical targets
• Recognition not leading to action.

Additional factors related to the wellbeing and capacities of responders themselves:

• Staff overwork and burnout - despite steadfast commitment, many working on the rollout were at risk of burnout, thus endangering efforts to ensure vaccine equity.
• Limited support/communication from national level - this sent local teams scrambling to implement policy or guideline changes with hours’ notice.
• Logistical challenges - these included transporting and knowing how much vaccine (including of different types) would be necessary for a pop-up site.

Over time, those involved in the vaccine rollout found the following activities enabled greater vaccine equity. These lessons learned included:

• Shifting from centralised to decentralised modes of delivery
• Communicating registration/identification is not necessary
• Community engagement (CE)
• Active listening to people on the ground
• Collaborative, flexible and joined-up working
• Supporting/working with community groups.

As we approach the end of the pandemic and following a highly successful vaccination campaign, there remains a need for local authorities to focus on equity and reaching those yet to be fully vaccinated against COVID-19.

There is also a need to apply lessons for equity to other critical public health issues. Below are some key considerations for local partners to focus on going forward:

• Enhance data driven approaches and complement with qualitative evidence.
• Sustain, strengthen and adapt collaborative and joined-up approaches to working between local authorities, NHS, community groups and beyond.
• Establish and support mechanisms for more decentralised action for vaccination and other key health and social services.
• Emphasise ‘going to’ residents, especially less visible groups, moving beyond more conventional forms of engagement such as public forums and webinars which may attract only residents who are already more engaged.
• Support community response with resources for community organisations to implement action, facilitate 2-way information flows, and meaningfully participate in decision-making.
• Increase attention to vulnerable groups in Ealing to close vaccine and health equity gaps.
• Respond to people’s multiple needs, as vaccination or other targeted public health measures may not be a priority for many who struggle with poverty, including in-work poverty, precarious work, inadequate housing, and other challenges.
• Place greater emphasis on residents’ lived experiences, perceptions, and priorities (qualitative data).
• Encourage and enlist support of local political leadership that recognises and represents residents across diverse social groups.
• Encourage greater engagement of GPs and other health professionals.