Improving access to catch-up immunisations for humanitarian arrivals: a qualitative study June 2024, Volume 34, Issue 2

Introduction

No one arriving as a refugee or asylum seeker to Australia will be up-to-date with vaccinations aligning with the Australian National Immunisation Program (NIP) Schedule.¹ This is due to a multitude of reasons inherently related to the refugee experience, including differing vaccine schedules in each country and pre-arrival barriers to accessing healthcare.

Refugee health centres have been established in some areas in South-East Queensland, where new arrivals are offered a thorough health assessment and initiation of catch-up immunisations.² Following this initial visit, the person is referred to a general practitioner (GP) in their local area for ongoing follow-up care of outstanding health concerns and completion of their catch-up immunisations. However, there is no refugee health centre on the Gold Coast (an area 66 km south of Brisbane), so those settled in that area are referred directly to a few local GPs (see Figure 1).

Figure 1.    Phases experienced by refugees in acquiring immunisations in South-East Queensland (click figure to enlarge)

^a  Voluntary, for visa-holders, in the week before travel and incomplete uptake
MMR = measles, mumps and rubella vaccination

However, few medical centres in the Gold Coast currently provide follow-up for refugees, with more centres moving to private billing³ or unwilling to see humanitarian arrivals. In addition, these primary care centres are in areas where humanitarian arrivals have historically been settled due to housing affordability. With rising housing costs, however, people are being settled further away from the city centres, leading to poorer access to primary care providers.⁴ Humanitarian arrivals on the Gold Coast can currently receive all NIP vaccines at community immunisation clinics at no cost, but many are not aware of this service.

In the last 10 years, there have been a total of 19 626 people with a humanitarian visa settled in Queensland, with approximately 2% settled on the Gold Coast.⁵ There was a 44% decrease in offshore application lodgements in 2020–2021, due to the coronavirus disease 2019 (COVID-19) pandemic, but numbers are expected to rise again with borders reopening to international arrivals.⁶

There have been no recent attempts to explore the barriers experienced by both humanitarian arrivals and vaccine providers in organising catch-up immunisations, and none in the Gold Coast region, with most studies dating back a decade or more ^7-11 Noting the existing refugee health centre in South-East Queensland is unable to service the Gold Coast region, exploring barriers and solutions to accessing catch-up immunisations by this priority population is vital to prevent outbreaks of vaccine-preventable conditions.

Methods

Semi-structured face-to-face interviews were undertaken with key stakeholders recruited via purposive sampling between October 2022 and January 2023, using interpreting services as required. Voice recordings were made of interviews, which were conducted with informed verbal consent. Participants were community members who had arrived on the Gold Coast as refugees, as well as refugee health service providers based on the Gold Coast. The Human Research Ethics Advisory Committee at Gold Coast Health reviewed and approved the study (HC89026). Key themes were identified and coded using inductive thematic analysis.

The interview guide for refugee health service providers covered an overview of the population they service, as well as challenges faced when organising health services for their clients. A peer-research model was used to develop the community member interview guide, with assistance from community leaders and staff from multicultural organisations. The questions related to the following topics: knowledge about immunisation, prior immunisation experiences, perceptions towards immunisation, and barriers and facilitators to accessing immunisation services on the Gold Coast.

Results and discussion

Twelve refugee health service providers were interviewed and included six registered nurses, three doctors and three staff members (including case workers) from multicultural organisations. Most of the participants (7/12) had worked more than 20 years in their field. The interviews covered eight medical practices and two multicultural organisations on the Gold Coast. Of the eight medical practices represented, five currently see humanitarian arrivals in their practice, two had recently ceased seeing humanitarian arrivals, and one had not seen any newly settled humanitarian arrivals.

Ten community members who had arrived in Australia as refugees were interviewed, with the majority having settled in Gold Coast between 2018 and 2019. They were largely from Eritrea or Ethiopia, reflecting some of the most common countries of birth for those settled on the Gold Coast.⁵ All had received a vaccination since arriving in Australia, but only half had received a vaccine other than a COVID-19 or influenza vaccine.

The main themes that emerged from both groups were local issues with accessing housing and healthcare on the Gold Coast, specific issues with primary care including time pressures, use of interpreters and lack of health professional training about cultural safety and catch-up immunisations, as well as gaps in adult immunisations (see Supplementary table 1 for more information, available from: doi.org/10.6084/m9.figshare.25706550).

Service providers suggested some strategies to address barriers, including appropriate training and adequate remuneration for the time and complexity involved in organising catch-up immunisations. They also advocated for a computer system to identify new arrivals with refugee backgrounds among their clients from culturally diverse communities, translated resources about vaccine-preventable diseases and more consistent messaging about immunisation (see Supplementary table 2 for more information, available from: doi.org/10.6084/m9.figshare.25706550).

Specialised refugee health nurses were highly valued as they were able to complete the more complex and time-consuming aspects of the health assessment. This was preferred by primary care providers, so they could focus on the ongoing care of these patients.

Some solutions identified in this project that could improve the existing Gold Coast community immunisation clinics include consistent messaging, improved cultural awareness and interpreter training, and the provision of translated resources to families.

Despite outlining barriers to vaccine access, community members reported high vaccine acceptance, which was a recurring divergent perspective, as it was anticipated that vaccine hesitancy would be a potential barrier. There also appeared to be a reluctance among community members to suggest possible solutions to improve access to catch-up immunisations. This project limitation may be due to the confronting nature of the Australian practice of fully explaining the consent process for participation in the research, which may have made some community members reluctant to discuss issues they faced.³ In addition, our participant recruitment strategy was purposive and facilitated by multicultural organisations, so there is a risk of social desirability bias. The community members may have responded in a manner that is considered socially acceptable, hence affecting the validity of the results.

Conclusion

Approximately one-third of permanent humanitarian visa holders settled in Queensland live outside the main local government areas⁴, so equitable access to catch-up immunisations is vitally important in preventing outbreaks of vaccine-preventable diseases. There needs to be geographically targeted strategies supporting primary care access for priority populations, including humanitarian arrivals. Ideally, these strategies would be consistent nationwide and utilise a whole-of-practice approach with input from community members, practice nurses, medical practitioners, and multicultural organisation staff.

Peer review and provenance

Externally peer reviewed, not commissioned.

Copyright:

© 2024 Ginige et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.