Title: Engaging migrants in UK primary care to improve vaccine delivery
Funder: Department of Health and Social Care

Abstract: Research question My research will answer a critical question around how best to approach strengthening UK vaccine delivery to under-immunised migrants to lessen their risk of vaccine-preventable diseases. Background Migrants represent an under-immunised group in the UK, with adolescent and adult migrants in particular excluded from initiatives to promote catch-up vaccination on arrival. Ensuring that under-immunised groups receive vaccines is a cornerstone of the UK vaccination system, alongside a need to better define at-risk migrant groups and engage them in the development of acceptable strategies. Aims and objectives The overall aim of this project is to define strategies to engage migrants in the promotion of catch-up vaccination. There are three objectives: Objective 1: Develop and test an innovative catch-up vaccination tool targeting adolescent and adult migrants presenting to UK general practice to align them with the UK vaccine schedule; Objective 2: Do an evidence synthesis to investigate rates and predictors of under-immunisation in migrants, and the relationship between migration and incidence of vaccine-preventable diseases in the UK; and Objective 3: Engage with migrants and healthcare professionals to evaluate the tool and define strategies to improve vaccine uptake. Methods A Project Advisory Group will be set up, including PPI representatives. In Objective 1 I shall develop and test through a prospective exploratory study an innovative catch-up vaccination tool that I have designed with support from Public Health England. This tool will be used when migrants first present to general practice to facilitate data collection on previous vaccinations and deliver catch-up vaccinations required. In Objective 2 I wilI use systematic review methodology to explore the role of migrants in outbreaks, a geospatial analysis using secondary data sources, and a comparative database analysis using data from high quality Danish national registries, linking data on at-risk migrant groups in Denmark with the UK. Synthesising these data will identify key at-risk migrant groups across all parts of the UK, and define the relationship between migration and incidence of disease. Raising awareness among migrants and thus empowering communities is a key step in developing successful public health programmes and is a core focus of Objective 3, where I will engage a migrants and health-care staff through a qualitative interview study to evaluate the tool and explore barriers and facilitators to vaccination, alongside promoting public engagement through a roundtable meeting bringing together at-risk migrant groups.Timelines for delivery I am requesting a 2-year Advanced Fellowship across a 40 month period (0.60%WTE), which includes the recruitment of a nurse (months 1-28 100%WTE) to support Objective 1.Anticipated impact and dissemination This research will have important and impactful consequences in terms of changing practice in UK primary care, guiding PHE in delivering their national immunisation strategy, addressing data gaps, improving knowledge, and raising awareness in migrant communities and among health-care professionals around strategies to delivering catch-up vaccination, aligning with national priorities. A minimum of 4 peer-reviewed publication will be generated alongside a report of the research findings for dissemination, and a roundtable meeting will bring together at-risk migrant groups.

Lay abstract: The vaccination of migrants is an important but poorly evidenced aspect of public health policy in the UK, and innovative service-delivery approaches are required to increase vaccine coverage. The overall aim of this project is to define strategies to engage migrants in the promotion of catch-up vaccination, and improve vaccine delivery.Migration to the UK has risen substantially in recent years. Migrants come from countries with poor health-service infrastructure or where vaccination systems have broken down due to war or poverty, and are recognised to be an under-immunised for infections including measles, mumps, and diphtheria. As a result, they may face greater disease, disability, and deaths from vaccine-preventable infectious diseases and may be an important population involved in outbreaks, which poses considerable implications for individuals, migrant communities, public health, and NHS resources. A migrant's ability to get vaccinations is often limited by barriers to accessing national health services and lack of provision. In the UK, it is a government priority to ensure that migrants are adequately vaccinated, and innovative approaches are now needed within the NHS to facilitate this.I have shown that it is adolescent and adult migrants (over 16 years of age) who are excluded from catch-up vaccination initiatives, with children under 5 targeted in primary care and older children identified through school-based screening. The failure to vaccinate has resulted in recent large pan-European epidemics; there have been five measles outbreaks in the UK alone in 2017. The objectives of this project are to develop and test an innovative strategy in UK primary care to promote engagement of adolescent and adult migrants in catch-up vaccination, alongside synthesising existing and new data to investigate migrants' risks of vaccine-preventable diseases. This will help me to define at-risk migrant groups in the UK, and to specifically engage migrants around strategies to promote catch-up vaccination. In the first part I shall develop and test through a prospective exploratory study across 10 general practices an innovative catch-up vaccination tool that I have designed with support from Public Health England. This tool will be used when migrants are first seen to determine what vaccinations migrants have had and what they require, prompting the nurse to administer any required vaccinations. The second part is an evidence synthesis of new and existing data. This will include a systematic review to investigate the role of migrants in outbreaks by collating all publicly available evidence, and a geospatial analysis and comparative database analysis to identify which specific migrant groups in the UK are disproportionately affected, using information from international databases and a comparator country (Denmark) with more comprehensive datasets on migrant health than the UK currently collects. In the final part, I shall explore the views of a diverse range of migrants and key primary care staff through an in-depth interview study and roundtable meeting around strategies to promote catch-up vaccination in migrants. I will seek their input into the further development of my tool, to facilitate a change of practice in UK primary care, and promote knowledge-exchange and engagement in this under-researched area. My previous PPI work has led to the development of this research proposal, and migrants will also be represented on my Project Advisory Board to support research delivery and dissemination and translation of findings.Improving vaccination coverage in migrants is a key national priority. This project will change practice, support Public Health England in delivering their national immunisation strategy, improve knowledge, and address data gaps to ensure equitable delivery of vaccination to excluded migrant groups.

Research activity codes: 3.4 VACCINES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: INFECTION