Catalonia ensures COVID-19 vaccine interventions leave no community behind

There is no one-size-fits-all approach to achieving a high uptake of COVID-19 vaccination. As immunization programmes roll out, alternative service-delivery approaches are needed to encourage some communities and social groups to get their jabs. Across Catalonia, Spain, public health professionals have excelled at tailoring vaccine programmes to ensure everyone has equitable access to COVID-19 vaccination. 

A wide range of tailored interventions have been necessary to encompass all of Catalonia’s demographic diversity. Early on, public health officials noted that low vaccination coverage coincided with areas of greater social disadvantage. By mapping vaccine rates geographically, officials identified who needed the most targeted interventions, as well as the social determinants which affected access to or uptake of the COVID-19 vaccine.

Homeless people in Catalonia were supported to get the vaccine. To reach this target group, it was necessary to draw on existing relationships between nongovernmental organizations (NGOs) and the individuals themselves, a high proportion of whom live in Barcelona. Reaching these people through social-care workers and NGOs ensured conversations about the vaccine took place on grounds of trust.

Catalonian officials also drew on the trust between existing organizations and community leaders to give Roma communities easy access to COVID-19 information and vaccination. Through surveys and consultations, questions about vaccination were brought to the attention of officials. These questions were authoritatively answered, but before being passed back to the community, they were re-worded by Roma community leaders to ensure appropriate phrasing.

Outreach to religious communities has also been important in Catalonia. “If you’ve been working with a certain mosque in a certain neighbourhood already, it’s easier to identify the best day to go for vaccination,” explains Carmen Cabezas-Peña, Deputy Director for Health Promotion at Catalonia’s Ministry of Health. “You know how it all works, how the imam interacts with the community. Working with these communities was vital to organizing suitable and respectful days for vaccination.”

Ana Marchal Torralbo is a nurse working in the metropolitan region of Barcelona. She understands the power of paying attention to community needs. “It’s necessary to go out into the streets, know the existing resources and work hand in hand with the people who know the health situation of each locality,” she says. 

Ana has helped coordinate meetings with leaders of Chinese, Pakistani, Moroccan and Indian communities to ensure everyone has culturally relevant care during the COVID-19 pandemic. She has also been involved in increasing the Muslim population’s access to the vaccine in the Barcelona region. 

“The first thing we did was talk to the community leader of the local mosque. He asked a lot of questions, like, ‘What is the vaccine for? What happens if my vaccine does not immunize me?’ Once he had all the information he needed, he agreed to have the vaccine. Most importantly, he asked if he could have a photo of himself getting it, which he put on his social networks to engage all his followers.”

Following this intervention from a locally respected figure, nurses arranged a day of vaccination at the mosque, which was hugely popular. However, Ana explains, only men attended. To ensure women were also accessing the vaccine, the nurses donned their traditional white uniforms to be recognizable as health workers, and went out into the streets to encourage Muslim women to attend the vaccine clinic.

Understanding barriers to vaccination has been critical to tailoring interventions. “We’ve also helped set up a vaccination bus, placed in strategic areas of the city,” says Ana. “This action facilitates access to vaccination for people who have trouble getting around, who have trouble finding the time, or who are very reluctant to leave where they come from.”

Independence is a key ingredient in the rollout of these vaccination programmes. “We try to respond to each person or each group, what they need to be able to improve, find or recover their health. From the outset, we want people to feel autonomous about the management of and decisions about their own health,” explains Ana. 

“To this end, we’ve worked together with city councils, public health, cultural mediators and the leaders of different communities. With all of them, we have worked to break the myths and fears and resolve doubts in relation to COVID-19 vaccination.” 

Ensuring access for migrant workers in rural areas

Eloisa Seto Gort is a nurse working in the predominantly rural area of Lleida in north-western Catalonia. She helped coordinate the vaccination campaign in her region, where over 20% of the population is of non-Spanish origin – higher than the average of 15.9% in the rest of Catalonia.

One of the reasons for this is the region’s large agricultural sector: 82% of the land used for fresh fruit production in Catalonia is in Lleida, and many people come for seasonal jobs as fruit harvesters. “There is no official figure for how many people travel to our region during the summer months, but it is estimated at around 20 000 to 30 000 people annually,” explains Eloisa. 

The region offers many job opportunities, but also generates vulnerabilities due to the precarious nature of seasonal agricultural work. Given this precarity, primary-care teams have had to work hard to ensure all communities have access to the COVID-19 vaccine, including those living in homeless shelters and illegal settlements.

By coordinating 172 local clinics, frontline workers have increased the level of vaccine-related information that is accessible to different population groups. This awareness-raising work has been carried out jointly with social workers, nurses, community health leaders, vaccination team leaders and cultural mediators. It has involved a broad communications strategy, ranging from translating materials to contacting local media.

“We set out to provide all the information we had in relation to safety and the type of vaccines available in our area,” explains Eloisa. “We travelled to places of worship, to mosques, to adult schools, centres for minors, agri-food companies, parents' associations and also businesses run by people from different countries.”

This effort did not come without its challenges. It was an intense job for mediators and social workers to correctly identify those who needed vaccination, particularly second and third doses, due to the undocumented nature of many of these workers. In informal settlements, vaccination certificates were provided by bringing a printer and computer to site visits. 

“It was important to include those without papers to ensure they could work,” says Eloisa. “There was a mutual respect between the vaccinators and those we were vaccinating.” The benefits were palpable: the fruit harvester vaccination campaign was a resounding success that saw 10 763 vaccinated against COVID-19.

Outreach in Lleida was also extended to the Muslim population. Crucially, 17 clinics were organized next to the most important mosques in the region during the hour before and after prayer. This was done in 2 lines, 1 for men and 1 for women. 

“We observed, especially at the start, the great sense of relief that this was the beginning of the end,” Eloisa explains. “This was true, especially when people came to get vaccinated who were from more socioeconomically disadvantaged groups. It was a levelling moment, everyone was vaccinated without discrimination.”

Ana has an important message about resilience for future vaccination strategies: it’s not just getting jabs in arms that matters, but doing the deeper community work that makes it possible. 

“The pandemic shows us that it is necessary to continue investing in community work, because now, after the pandemic, there are other effects such as the impact on mental health and the worsening of the economic crisis. I think we have seen that community health is important and that we must continue working closely on it, to help with further emotional and mental challenges.”