With limited COVID-19 vaccine supplies available during the first quarter of 2021, countries across Europe were faced with the difficult task of determining which demographic groups to prioritise for vaccination.
Most countries globally have opted to protect the population groups who are most vulnerable to severe cases and death from COVID-19, namely older populations and those who experience high rates of exposure (i.e. health and social care workers). In the next phase of the vaccine rollout, governments must choose whether or not to continue vaccinating those most at risk of severe disease and death (i.e. individuals with comorbidities) or those most prone to spreading the virus (i.e. essential workers). The fraught ethics of these vaccine prioritisation decisions are further complicated by the disproportionate burden of COVID-19 on Europe’s hard-to-reach populations, such as homeless, migrant, and travelling populations.
Hard-to-reach populations are difficult to access due to geographical location and/or socioeconomic factors. Many of these groups have experienced poor outcomes throughout COVID-19 due to inequalities in access to clean water and sanitation services, masks and other personal protective equipment, and educational and informational resources. These inequalities, and their subsequent impact on health, make hard-to-reach populations a particularly vulnerable group.
Hard-to-reach populations have disproportionately experienced the negative impacts of COVID-19; therefore, they are not only a crucial demographic for governments to vaccinate, but also require coordinated strategies to ensure they have equitable vaccine access. This analysis outlines the most commonly adopted strategies across the European Region. Information was collected from the COVID-19 Health Systems Response Monitor (HSRM) (up to 21 April 2021).
Countries have recognised the needs of hard-to-reach populations
In general, many European countries have acknowledged the importance of – and difficulties associated with – contacting and prioritising hard-to-reach populations throughout the pandemic for a variety of purposes, including communication about prevention measures and regulations, access to testing and routine health services, and supporting basic needs such as food and housing. Governments have responded with several strategies.
Armenia, for example, has provided direct financial assistance to vulnerable households to offset economic hardships brought on by pandemic containment measures, while Denmark has provided targeted aid to pay for hotel rooms for unhoused individuals, and Spain has developed a specific protocol for prevention measures for hard-to-reach, vulnerable populations. Ireland, Poland and Portugal all have community and volunteer programs to support a variety of marginalised communities, including the unhoused, those in shelters, and those requiring addiction services, while North Macedonia has focused on providing food for disadvantaged populations. Romania has specifically addressed the difficulty in reaching the Roma population by providing direct financial assistance, informational campaigns as well as culturally-adapted health promotion services. However, all of these countries’ responses were reported on before vaccines became available. Thus, these strategies may or may not be integrated with the national vaccination plans.
Few policies address vaccine-specific responses
As vaccination discussions have commenced, hard-to-reach populations have been largely excluded from policymaking conversations and the following prioritisation groups. In fact, most countries have not explicitly included hard-to-reach groups in their policies.
While a few countries – including Austria, France, Latvia, Luxembourg, Romania and Slovakia – have specifically mentioned hard-to-reach populations in their priority groups (e.g., the homeless, Roma, and asylum seekers), they remain relatively low on vaccination priority lists, typically one phase above the general population. However, inclusion on the list does not equate to countries having effective strategies to reach these populations, inform them about the vaccines, or provide access to vaccination itself. For example, while Austria’s vaccine strategy prioritises homeless and asylum seekers, in order to be eligible for vaccination individuals must be in an official government residence, limiting the scope of the strategy. France mentions “deprived populations” in its vaccination rollout; however, it only specifies the homeless population and those living in psychiatric institutions. Slovakia similarly indicates the inclusion of homeless populations but does not detail how to reach them. This is similar to Latvia’s strategy, which also highlights reaching only the “hard-to-reach” that have been institutionalised or have found a place in a shelter.
Other countries, including the United Kingdom, Sweden and Croatia, have recognised the need for specific responses and prioritisation of hard-to-reach groups, but acknowledge that they do not have a plan for implementing targeted programming to reach those populations.
Figure 1 provides a map of Europe with countries shaded in different colours representing different policy responses.
Belgium provides an example of a specific and targeted approach
Very few countries describe specific strategies to engage with hard-to-reach populations. Belgium has one of the most detailed strategies, which includes providing vaccine-specific information in 38 languages, collaborating with on-the-ground, pre-existing organisations, and recognising the need for mobile vaccination clinics that minimise the geographic and socio-economic barriers associated with requiring hard-to-reach populations to travel to vaccination sites. Additionally, the Belgian plan acknowledges the difficulties in communicating with these groups and emphasises a multifaceted vaccine promotion campaign that uses official websites, social media, and print documents to spread information. The strategy recognises the need to adequately and competently respond to vaccine hesitancy as well as that the diversity of groups within the umbrella of the “hard-to-reach” designation will be concerned about a wide variety of issues, such as those within some of Belgium’s ethnic minority communities due to fears surrounding potential fertility implications.
In stark contrast to previously mentioned country strategies regarding homeless populations, Belgium also specifically acknowledges that homeless people will need to be reached both in shelters and in the field as well.
Bulgaria has addressed this need as well, designating mobile clinic capacity specifically for hard-to-reach and remote settlements.
Israel has taken a community-level approach
In some countries without a national strategy targeting hard-to-reach populations, state and municipal governments have taken responsibility and have implemented targeted campaigns. For example, in Israel’s largest city, Tel Aviv, the municipality opened a vaccination centre to provide the vaccine free of charge for homeless people and undocumented immigrants.
National policies could go beyond acknowledgement and include decisive action
While most European countries acknowledge the importance of reaching and vaccinating hard-to-reach groups, very few have published operational strategies on how they will do so. Although several countries place hard-to-reach populations as a priority vaccination group above the general population, likely due to the disproportionate impact that COVID-19 has had on them, they do not support this prioritisation with clear guidelines on how to ensure vaccine access.
It is thus crucial that governments go beyond acknowledging the needs of hard-to-reach populations and instead prepare to act. This entails decreasing barriers to vaccination information and distribution through methods such as providing information in multiple languages; providing non-technology reliant information; collaborating with community leaders and groups who already engage with hard-to-reach populations to facilitate trust; and creating more mobile and flexible options for vaccine delivery and administration. The need to develop these strategies grows more immediate as Europe enters a third wave and simultaneously strengthens its vaccine response to include additional priority groups.
Ines Siepmann, Shelby Fisher, Brian Li Han Wong, Jose M Martin-Moreno
On behalf of the ASPHER COVID-19 Taskforce