1. Childhood Immunisation with reference to MMR and a case study of the factors shaping low MMR coverage in an under-immunised group.
Dr. David Smith

2. Introduction
Resurgence of measles and sharp increase in measles in the UK peaking at over 6000 cases in
1998 discredited Wakefield study linking MMR to autism and bowel conditions coverage fell from 92% in 1995 to 80% in 2003.
coverage increased to 92% of 2 year olds below the 95% coverage required for a population to develop herd immunity.
Coverage lower in low income groups, some immigrant communities, asylum seekers, some orthodox religious groups and among Gypsies Roma and Travellers.
Also geographical disparities in coverage globally and nationally.

4. UK MMR1 coverage at 2 years 2013-14
England
N/E
N/W
Yorkshire and the Humber 94.7
E Midlands 94.9
W Midlands 93.6
E England 93.7
London 87.5
S/E 91.8
S/W 94.2

5. Factors explaining low uptake rates in London
Diversity – over 300 languages and 90 different BME groups.
Transient population – patient turnover 20-24% on some GP lists.
High indices of population – 34% of children in poverty.
24% of children live in HHs where no adult is employed compared to 18% nationally.
High proportion of unregistered patients which is difficult to quantify.
Factors make accurate recording and targeting of populations difficult for commissioners and providers.

6. Background to case study……
Background to case study
Estimated ,000 G/TAS in the UK (not including est ,000 Roma from E and C Europe) and largest EMG in 13% of LA’s.
Plus ,000 Roma migrants from E&C Europe (one of the largest populations in W Europe)
Approx 2/3 in housing. ODPM 20-25k caravans in UK – between 85-90k people.
72% on authorised sites; 16% on unauthorised sites and 12% on unauthorised encampments where they own the land but do not have planning permission.
Poorest educational status 23% of Gypsy and Traveller children and 42% of Irish Traveller children receive 5 GCSE’s grade A-C compared to 55% for the general population.
Highest level of permanent exclusions, SEN diagnosis etc.
By KS3 only 20-25% are registered or regularly attend school.

7. GRTs and health
Results of the quantitative findings show that Gypsy Travellers have significantly poorer health status and significantly more self-reported symptoms of ill health than other UK-resident, English speaking ethnic minorities and economically disadvantaged white UK residents…with reported health problems between twice and five times more prevalent
Parry, G. et al (2004)
Greater health need yet lower access than other members of the population.

8. Mental health: 32% of Gypsies and Travellers suffer from depression or anxiety compared to 21% of the general population and low take up of mental health services (Goward, P. et al, 2006)
Life expectancy: on average women live 12 years and men 10 years less than the general population (CRE, 2004)
But GTAA’s give a more mixed picture highlighting the role of accommodation and access to medical care.
Parry (2004) 1/3 of Gypsy women had experienced one or more miscarriages compared to 16% of non Gypsy women and 17% of women had experienced the death of a child (excluding miscarriage) compared to less than 1% of the comparator group.
Or artefactual e.g poor health as a result of the subsections of the GRT population sampled to take part in health surveys?

9. Immunisation and MMR
Lack of systematic evidence on MMR take up – small scale local studies.
Twiselton and Huntington, (2009) Only 20 per cent of those living in caravans or trailers and 57 per cent of those in housing fully immunised.
Dar et al (2013) only 4 of 22 PCTs estimated MMR coverage of 90 per cent or above on Gypsy/Traveller sites in their region.
Clusters of measles outbreaks reported e.g in the Thames Valley region 63 per cent of outbreaks between 2006 and 2009 were in GRT communities, x100 higher than the general population (Maduma-Butsche and McCarthy, 2012).
March - June 2007, of 173 cases of measles reported in seven UK regions 156 were in Irish Traveller communities (Cohuet et al, 2009).

10. Culture and Health
Role of cultural attitudes, beliefs and practices in explaining poor health outcomes of GRTs e.g fatalism, stoicism, suspiciousness, concepts of hygiene and taboo (Vivian and Dundes, 2004; Dion, 2008).
Critics – can complement a ‘cultural deprivation’ framework for explaining health inequalities.
Alleyne (2002) the ‘ethnic community’ concept presents an ‘epistemological obstacle’ when used as an explanation rather than something to be explained.
Minimises the role of social structural factors and obscures the direction of causal processes.
Aim – to explore social/contextual issues that frame GRT parents decision making re: MMR and its relation to underlying social structures

11. Methodology and Aims
Cross sectional qualitative study – 5 focus groups with 16 GRT mothers living on caravan sites in Kent. Between them they had 35 children 22 fully or partially immunised and 13 not.
Kent highest population of GRTs in the UK.
Focus groups lasted 1-3 hours and explored:
1) Experiences and beliefs about childhood immunisation;
2) Beliefs about the risks of immunisation and non-immunisation;
3) Perceptions of obstacles to, and facilitators of, immunisation;
4) Views on increasing participation in immunisation programmes.

12. Lay understandings of causation and risk
Clear and accurate understanding of how measles is transmitted – provided numerous examples of it being spread at social and cultural events (weddings, funerals, horsefairs etc)
“That was all around the funeral, that's where they picked it up - you know, my Johnny picked it up there […]Everybody you spoke to had them. Everyone you spoke to then, someone had it. It was like wildfire wasn't it going through the travellers. It spread so fast.”
Risks commonly viewed as situational and would take up immunisation when necessary.
“Well, obviously, if they do catch one of those [MMR] uncommon diseases it could endanger their lives – yes, you’ve got that risk. But they’re so uncommon around where we are. If I was to travel into a country where those diseases are common, with my children, I might think differently”

13. Environmental/ living conditions
Overcrowded public sites and living in close proximity.
“I think it goes in the air or something like that. Once you've been in contact with a person, so many people had it…’’
Isolated location of many sites
“Most camps are miles away from the shops even now aren’t they? It’s very rare you’ll get one close to shops. Far from doctors, far away from health care, no bus route…if it’s easy access definitely because like I said we don’t always live on a bus route.”
Geographic and social isolation excludes people from access to information and knowledge.

14. Lack of knowledge
Geographic and social isolation excludes people from information and knowledge. Conventional methods of health promotion such as information leaflets and letters are less effective at reaching GRT communities, while outreach services are insufficient
“There are letters and things, I can read a little bit but I still don’t understand what they are going on about.” (FG1)
“A lot of travelling children don’t go to school for as long as other children. I don’t think they are offered the same information and awareness and what have you.”

15. Factors related to nomadic lifestyles and legislation
Tougher enforcement towards unauthorised camping and a shortage of stopping places = difficulties accessing health services.
“You get an appointment and then when you get to the appointment you’re moved on again. Then if you do get the appointment and you’re booked in you’ll be moved on again because you never get longer than a week or two weeks is the very most you’ll get to stay in one place.”
“We’re always on the road and you can’t get to a clinic or you can’t get to a doctor because you have to have a fixed address all the time.”
“I didn’t get my child immunised because I travel too much and there wasn’t a clinic that would let me immunise him.”

16. Anticipatory discrimination and interactions with healthcare staff.
Yougov poll GRTs most despised group in UK society with 58% of people feeling ‘ill disposed’ towards them.
Parry (2004) identified a ‘defensive hostility’ when engaging with healthcare staff.
Some – a lack of trust in health advice and health staff.
“They don’t tell you the side effects of having these vaccines they don’t tell you this side of it. They only tell you that yes it will stop measles, mumps and rubella they won’t tell you that it causes your child to have fits later on in life.”
“They [health professionals] don’t care they don’t really care about this population. If they would care about this population they will make the effort to pop along to the site.”

17. Perception of children as vulnerable to illness
High burden of childhood illness in GRT children. Made some averse to causing them more suffering.
“Nothing could encourage me to have a needle put in my baby’s arm or leg and scream his fucking head off.”
“…When he was small – he was really small, he got pneumonia. Because he’d had pneumonia I didn’t want to give him the needle either.”
However the opposite was also true and influenced some mothers to immunise their child/ren due to the perception of their health as precarious.
“I’m definitely going to get him [son] done with the MMR because he’s been so sick since he’s born anyway with viruses and ear infections.”

18. Minimising risks associated with MMR
Many considered the recommended age of months for the first round too young.
“Travellers don’t get it now until your children go over five, they won’t get it. They reckon to get it later on.”
Preference for spacing immunisations separately rather than the triple dose. However this is only available privately meaning this was not an option for many.
“It’s a really unnecessary overload into such a young body if you just dump so much into it. This is why so many children get ill.”
“I think they put a price on it if you want it individually and I couldn’t do that.”

19. Social networks and informal sources of knowledge
Structure of social relations in GRT communities (e.g strong bonding ties) ensures a conformity of behaviour and stories/anecdotes circulate widely.
“Jen who has the autistic child she believes it’s that [MMR] so that’s why people will hold back because of that especially everybody who knows her and her child.”
“Just visiting other travellers, then if someone tells family they think something’s going to happen to their baby, they’re not going to take a risk.”

20. Conclusion
Few opposed to MMR in principle and no consensus over MMR – objections were practical and/or pragmatic.
Influence of cultural v structural factors have important implications for engaging marginalised groups e.g to what extent do cultural practices and beliefs shape social outcomes and to what extent do social factors shape collective patterns of behaviour and attitude?
More significant than cultural factors were:
i) the lack of tailored services or outreach.
ii) situational constraints based in historical and contemporary experiences of marginalisation.
iii) the existence of social and health inequalities, which precede and inform decisions surrounding vaccination.

21. Policy Implications
Policy implications – stress on ‘cultural barriers’ and perception of GRTs as ‘hard to reach’ legitimises minimal progress in reducing inequalities.
Replicated in views of many health professionals and practitioners.
Structural inequalities, discrimination and exclusion main causes of poor health – policies should be focused on reducing social and economic inequalities.
Lack of political will e.g UK government’s failure to develop a National Strategy for Roma Inclusion – mainstreaming approach
In the UK we have a strong and well-established legal framework to combat discrimination and promote equality. That protects all individuals, including Roma, Gypsies and Travellers from racial and other forms of discrimination (UK National Strategy section 2)

22. Any questions?

23. Dr Paul Newton & Dr David Smith
Thank you
Thank you
Dr Paul Newton & Dr David Smith
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