Hi and welcome to BJJP Interviews.

I'm Nada Khan and I'm one of the associate editors of the Journal.

Thanks for taking the time to listen to this podcast today.

In today's episode, we're speaking to Dr. Carol Basta.

Carol is a public health registrar based in London and we're here to talk about the paper she's recently published here in the bjgp, which is titled Predictors of Childhood Vaccination Uptake and Timeliness in a Diverse Urban Population.

So, hi, Carol, it's really lovely to meet you and to talk about this work.

And I guess just to start, I wanted to put this work into context.

We know that in the uk, overall childhood vaccination rates have unfortunately been declining.

Could you talk us through some of the current challenges around vaccination, especially in urban and diverse areas?

Yep.

So we know vaccinations are really powerful and cost effective tools we have in giving children the best start in life life.

But unfortunately, in the UK, since 2012, the uptake has been declining and actually since 2021, none of the vaccines in England have reached the 95% target recommended by the WHO to stop communicable disease outbreaks.

And the kind of negative consequences of this aren't just sort of future hypothetical risks.

We've already been seeing vaccine preventable diseases such as measles and whooping cough resurgences, and this is especially in certain parts of the uk, such as London or the northwest of England.

So no uptake of vaccines is decreasing and vaccine preventable diseases are increasing.

But that's not the full picture.

We also know, for example, following work done by, at the time, Public health England in 2017, there are avoidable inequalities across the childhood vaccination program nationally, for example, linked to deprivation, geography and ethnicity.

However, what was missing was really kind of contemporary granular evidence on the social and clinical factors associated with unequal vaccine outcomes, especially in diverse urban environments.

And I know this was highlighted as well during COVID but there is a mistrust of health services amongst some communities as well, which might be playing into this.

Yeah, exactly.

So at the time when I was working in Lamb of Council, we knew qualitatively from talking to our community and talking to our local GP partners, that there was kind of sense of rising mistrust in healthcare services, but also rising difficulties with actually access to services.

And that doesn't just affect whether or not people can get the vaccine, for example, it also affects whether they can have conversations about vaccines and the kind of continuity of care and building up those relationships.

And so this is what we had kind of on a local level, but we knew that there was also national feelings and sentiments around mistrust, not just national, but actually globally vaccination mistrust from the COVID 19 pandemic.

And there were worries that this had run off into the childhood vaccination program as well, that it hadn't just confined itself to Covid vaccines.

So this was a study looking at predictors of routine childhood vaccination from 40 general practices in Lambeth and London, which is a pretty ethnically and socioeconomic demographically diverse borough.

And you looked here at the vaccination uptake and timeliness and some of the predictors for these.

This was a really big sample.

But just to underline the population here, tell us more about the demographics in Lambeth as a borough in terms of ethnicity, because that's where you were based when this work was done.

Yeah, exactly.

So Lambeth is an inner London borough and it is very ethnically diverse, it's very densely populated, but it also has some of the highest levels of deprivation in the country.

And part of the strengths of this study is that we were able to use detailed ethnic subgroup breakdowns.

So, for example, rather than using the broad category of South Asian, we were able to split this down into Pakistani, Bangladeshi, Indian, et cetera.

And this was really important because this aligns with national health equity guidance.

We know that health outcomes actually vary between the details, subgroups.

There's some evidence to suggest that, but it was also important following local community engagement work, where people repeatedly told us these kind of big, broad groups don't reflect how we self identify.

And I wanted to just move on to the results here, so can you start talking us through some of the associations based on deprivation to start with?

Yeah, sure.

So we looked at two main outcomes.

We looked at vaccination uptake, so that's whether children had received their vaccines at any time point during the study.

And we also looked at vaccination timeliness.

And vaccination timeliness is important because although a child might eventually go on to receive their vaccine, it leaves them.

They're late, it leaves them unprotected for at times when they're most potentially likely to get unwell.

And what we found with deprivation in uptake, there was really clear patterns associated by deprivation.

There was actually children living in more deprived areas were progressively less likely to be vaccinated compared with those living in the least deprived areas.

So, for example, children living in the most deprived 20% of our population were about a third less likely to be fully vaccinated compared to those living in the least deprived areas.

This kind of wasn't just a straight out deprivation.

There was also lower uptake linked to other markers of social vulnerability, such as being born outside of eco, or such as children having safeguarding involvement.

And so that was what we found for uptake.

But what was interesting is the findings for timeliness didn't mirror this.

So whilst those living deprivation were less likely to be vaccinated, if we zoom in on just the population that were vaccinated and think about were they vaccinated on time, we didn't find that children living in deprivation were less likely to be vaccinated on time.

We found no difference.

And there was a similar pattern for other markers of social vulnerability, such as safeguarding involvement.

They have a lower uptake, but it wasn't associated with kind of untimely vaccination.

And you've touched upon this, but there was a really striking result here in terms of children who were born outside of the uk.

So can you talk us through this?

Yeah.

So we also found that children born outside of the UK were much less likely to be vaccinated compared to children born inside the uk.

However, if again, we zoom in on just those vaccinated and look at timeliness, we actually find the opposite.

So if you were born outside of the uk, you were more likely to have your vaccine delivered on time compared to those who were born in the uk?

Sure, yeah.

So talk us through some of the reasons that you think that this might be happening.

Yeah, I think these findings, the difference between uptake and timeliness, not having the same predictors and in some case having the opposite patterns being shown are really quite interesting.

And they're kind of a few possible explanations as to why this might be.

One is perhaps potentially there's a form of selection going on.

So when we look at only children who get vaccinated in groups with lower overall uptake, for example, children of non white British ethnicity, or as we've said, children not born in the uk, the children who do get vaccinated may represent more engaged, health literate or well supported families.

And that same engagement may also support timely vaccination.

But in groups of higher overall uptake, for example, children of white British ethnicity or children born in the uk, the groups who do get vaccinated may include a kind of broader, more mixed group of families, including some who vaccinate later, which can then reduce their overall level of timeliness.

And this raises the possibility that our kind of existing recall and catch up systems may work better for some groups over others and in doing so may actually unintentionally reinforce inequalities rather than reduce them.

But there are other alternative explanations and I think what's really key here is future research is really important.

Timeliness has generally been less well described and these findings potentially raise important questions.

So it's definitely an area where both qualitative work and also future quantitative work I think would be helpful.

And you've touched a bit about the deprivation and children born outside of the uk and in this cohort, as you said, you were able to get quite detailed information about ethnicity rather than sort of the broad brush groups.

Yeah.

What did you find here in terms of ethnicity and uptake?

So did it mirror some of the findings around children born outside the uk?

Yeah.

So compared to children of white British ethnicity, lower uptake was observed with all other ethnic groups.

The largest gap was seen among children of black Caribbean ethnicity, whose odds of being fully vaccinated were around 70% lower than those of white British children.

But other groups such as Indian, Pakistani, Bangladeshi, Chinese, Arab and several other mixed ethnic groups also had lower uptakes, ranging between 30 to 50% lower than white British children.

And so all, although all groups had a lower uptake compared to white British, it suggests that the kind of barriers may not be experienced in the same way or to the same extent and could potentially reflect a combination of different structural, cultural and service related factors.

I think with all of these findings, I think it's.

I think there's two important things to note, is one, we found all of the inequalities were present for both individual vaccines.

And then because we looked at overall patterns across the schedule, they weren't just kind of isolated to one vaccine, they were found for all the vaccines for all different sorts of combinations.

And this was important for us to find, as some of our work qualitatively, but also some findings nationally suggested perhaps some communities have lower uptake relating to just the MMR vaccine, for example, but we didn't find that.

So this suggests that kind of these inequalities are unlikely to be driven by really specific parental concerns about one vaccine, but it's kind of more wider barriers to accessing vaccination services.

So I think that's one important thing to be aware of.

And then the second thing is that these inequalities are persisting after adjustment for a wide range of socio, demographic and clinical factors, as well as age as well as GP practice.

So that kind of indicates a Certain level of robustness to measured confounding.

But however, as of any observational study, there are unmeasured factors that might be influencing things.

For example, in this case, things like parental education or family size, which we weren't able to explore but would be interesting to do in further studies.

It's interesting.

You're talking about access as potentially quite a major contributing factor.

And one thing I was wondering was that, is it that there's more outreach needed to certain communities, or do you think it is sort of a matter of access to health care or an understanding about healthcare and what's being offered?

Really?

Yeah.

Research shows that it's often.

It's not necessarily just one thing, it's not necessarily just access, but it could be access combined with kind of vaccination misinformation or mistrust in the system.

So there's often multiple things going on which can combine to cause vaccination inequalities.

I think, though, given the kind of strong findings across the vaccination pathways showing structural and social influences on vaccination inequalities, access is going to be definitely part of the story.

And we also know this from qualitative research as well.

And so I think there are a number of things, not just general, general practices, but kind of different bodies that support general practice, such as national policy or integrated care boards.

I think there are definitely things that can be done in this space.

And I think, as you're pointing out, this study has shown some of those persistent inequalities present with vaccination uptake.

I think that actually your work as a public health doctor is really important to draw on here.

What do you think needs to be done at both the local or national level to start to tackle these inequalities?

Yeah, I think it's one of those things that requires a whole range of groups to play their part.

So I'd say there are kind of implications for GPs, implications for local teams, local integrated care boards, implications on a national level, and also implications for the research community.

It would be great to start with, what do you think that gps should be doing?

Because these are people coming in to see us or families that we might know over time.

So it would be really interesting to hear your thoughts on that.

Yeah, yeah.

We've hopefully established that this study has shown a broad range of social and structural determinants of vaccination, and these are across the pathway.

So I think practices are likely to have a greater impact by strengthening the overall vaccination pathway to work better for families.

Facing those barriers rather than focusing on individual vaccines or short term campaigns.

There are a number of ways this can be done.

Firstly, it's about making access easier, not more demanding.

So people who, families who are under vaccinated aren't necessarily even against vaccination, but they're juggling multiple competing pressures.

Life is challenging.

So practical changes like flexible appointment times, opportunistic vaccination during other consultations, walk in clinics, simpler booking and recall systems could make a real difference.

But it's not just the kind of process booking.

I think the experience of the appointment itself also matters, especially if it's kind of one of earlier on ones.

Feeling welcome, not rushed and having questions taken seriously makes families more likely to return and stay engaged with a vaccination program.

But I think there's kind of secondly work that beyond the practice walls that gps can take.

So having stronger links with health visitors, children's centres and safeguarding teams can help reach families who are just going to find it really hard to consistently engage with general practices.

And in some cases vaccination outside the surgery, for example, community settings or through health visitors, may be more effective.

And I think thirdly for practice, it's about building trust and continuity, which can sound kind of nebulous and difficult, but things like seeing a familiar clinician or having conversations in culturally sensitive ways can support engagement.

And I think people who might have concerns about vaccines kind of not to expect that suddenly one consultation is going to solve all their problems.

But it's kind of about visit upon visit building that trust and engagement.

I've said all of that, but I'm very aware that this is very resource intensive and requires upfront investment, which I think it also needs to be supported by national policy and changing some of the funding mechanisms.

I think, I mean, that's really the main point that I wanted to highlight was, you know, you're talking about things like health visitors or children's centers and things like that, and we know that funding for those areas is tight and being cut and I think possibly that this is where the impact is being felt.

Yes, yes.

And I think even before we get to things like children's centers and health visitors, which definitely their funding is being cut and needs to be, we can talk a lot about vaccination as uptake.

We need to use community centres, health visitors, but if the money's not there, it's not going to happen.

But I think even for general practice, funding for vaccination is linked to the number of vaccines given.

But if you're in a Deprived practice, a very ethnically diverse urban with lots of challenges.

You're going to have a harder job trying to vaccinate your population and you're also going to receive less funding because you're going to be doing less vaccines.

And so you can sort of.

It could just lead to a negative spiral of difficulties, reduced funding.

So I think our findings would suggest that you should ideally nationally really support practices with additional investment because this, this would help reduce inequalities, but it would also help increase uptake and relieve pressure on the system in the longer term.

I guess it's a question about equity really, isn't it, rather than inequality.

So it's about levelling up actually these structural issues that mean that these certain communities are having inequitable care.

Really?

Yes, definitely.

Anything else you want to point out from the paper?

Any other thoughts you have just about how the results of this paper could be taken forward?

Yeah, I think one of the really key things which I haven't mentioned is that I think this paper really shows the value of taking a place based approach and understanding your local data.

So although some of our findings reflected national trends, others diverged, highlighting that you really need to know your local context.

And in our case, using local primary care data to systematically explore vaccination inequalities helped us target resources and provided a clear focus for local action.

This in turn supported partnership working and co design of underserved communities, helping vaccination pathways become more locally appropriate and culturally competent.

And I think given this planned reforms that will move commissioning from more centralized arrangements to become more locally led through integrated care boards.

We really encourage other areas to take a similar place based approach.

And I think this work has definitely highlighted that, that local picture that's really important to take a deep dive into what's happening in somewhere, somewhere like Lambeth, which is quite a unique and very diverse population, which is clearly going to be different than looking at somewhere much more rural or much different or with a different sort of ethnic makeup as well.

So I think it's really important work to shine a light on that and just to help understand similar areas might, might want to take some lessons from that as well.

Yeah, exactly.

And even if it's, even if findings are similar to other places or nationally, it really helps as a kind of focus point for discussion.

And not everyone is necessarily, you know, people have different stakeholders for competing pressures, but when the data is there really showing stark inequalities, it's much harder to ignore and it keeps people accountable.

And it's not just doing it once looking at what the inequalities are.

But when you do interventions, monitoring that and seeing are we just improving overall uptake or are we actually targeting health equity?

Are we making things better for people who experience things worst?

Brilliant.

Well thanks very much for that Carol.

It's been really interesting looking at this in much more detail and hopefully some of the lessons from what you've done here.

We can sort of extrapolate and think about how we can apply this these findings around local inequity and think about how to tailor programs on the ground.

So I think that's really important work.

But I just wanted to say thank you again and yeah, thanks for taking the time to talk today.

No, thank you for inviting me and

thank you all very much for your time here and for listening today to this BJTP podcast.

Carol's original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com thanks again for listening.