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This is a co-produced report to inform inclusion health action in health protection.

The cover image is a cartoon of people sharing their perspectives on health inclusion. For an accessible version of the cover image, contact healthequity.queries@ukhsa.gov.uk.

Executive summary

Engaging with affected communities is a fundamental component of Inclusion Health approaches. Inclusion Health approaches aim to prevent and address extreme health inequities resulting from severe disadvantage and deep social exclusion.

These health inequalities include high rates of important infections and challenges in accessing vaccination, screening and clinical care.

Working with the broader health system, the UK Health Security Agency (UKHSA) has an important role in protecting inclusion health groups from infectious diseases and wider external health protection threats.

This report describes the findings of a coproduction process to develop recommendations to address barriers to health protection and broader healthcare for inclusion health groups. UKHSA commissioned 10 voluntary, community and social enterprise organisations (VCSE) to engage with people with diverse experiences of social exclusion to provide insights for designing and delivering health services that can meet health protection needs. Over 200 people with diverse experiences of social exclusion took part. The purpose of the engagement was to seek views on barriers and facilitators to health protection interventions and participants were encouraged to explore how services could better meet their needs.

The main recommendations that came out of this work were to:

1. Build trust first
2. Provide integrated, holistic, people-centred approaches
3. Build in accessibility to increase engagement and uptake
4. Tailor approaches to increase relevance
5. Embed peer roles

UKHSA intends for these insights to complement policy directions from the NHS 10-year plan to shift NHS care from sickness towards prevention and from the hospital to community. It will also complement the NHS Framework for Action on Inclusion Health and NICE guidance on Integrated Health and Social Care for People Experiencing Homelessness.

UKHSA is using the findings to inform its own approach to health protection preparedness and response for Inclusion Health groups. This includes ongoing engagement to ensure our approach is informed by those with lived experience. UKHSA will work with system partners to ensure these insights can inform development and delivery of services relevant to health protection alongside assessment of local need and provision.

Introduction

Taking an Inclusion Health approach is important to prevent and address extreme health inequities resulting from severe disadvantage and deep social exclusion in certain populations. This includes but is not limited to:

• refugees
• people seeking asylum and other migrants in vulnerable circumstances
• people experiencing homelessness
• people who use drugs
• sex workers
• Gypsy, Roma and Traveller communities
• people who are subject to modern slavery
• people in contact with the justice system

These populations often overlap and can experience multiple compounding risk factors for:

• poor health outcomes
• premature mortality
• chronic disease
• mental health problems

Infection risks can be high, vary by and within population groups and can include higher risk of:

• tuberculosis
• blood borne viruses (including HIV, hepatitis B and C)
• skin and soft tissue infections and infestations
• invasive bacterial infections
• sexually transmitted infections
• vaccine preventable infections (including hepatitis B, influenza, COVID-19, pneumonia, and vaccine preventable childhood infections)

Major barriers to care compound these risks and limit opportunities to deliver health protection and wider health interventions.

This report synthesises insights gained from engagement with over 200 people with lived experience of diverse forms of exclusion (covering all the listed Inclusion Health groups). The aim was to understand barriers and facilitators to health protection interventions, identify important components of inclusive healthcare and coproduce recommendations that can address high levels of unmet need.

The report is being published under the UKHSA Health Equity for Health Protection Initiative. The initiative aims to equip our staff and our partners across the health system with data, evidence and insights that can support UKHSA to tackle health inequalities in health protection.

Methods

Voluntary, community and social enterprise (VCSE) organisations working with specific inclusion health groups were selected to ensure coverage of all inclusion health groups (Annexe 1).

A structured consultation guide was developed by UKHSA covering:

• knowledge and perceptions of priority infections (blood borne viruses, tuberculosis (TB), sexually transmitted infections and vaccine preventable infections) and vaccines
• barriers and enablers to healthcare
• views on outreach of health protection interventions
• the role of peers 听

(Annexe 2)

Each VCSE developed their unique approach to engagement informed by their experience of working with particular inclusion health groups (see Annexe 3 for detailed methodologies). Separate engagement sessions were held with different groups, with the exception of Doctors of the World who summarised existing insights from previous surveys and engagement. Each organisation produced their own individual reports of their insights covering the topics included in the consultation guide and wider views on health that were expressed by participants (Annexe 3).

The VCSEs engaged over 200 people with diverse experiences of social exclusion overall. The coproduction process to develop the recommendations involved identification of important themes from analysis of reports. This was further complemented by the authors鈥� understanding of broader literature which reinforced the recommendation findings. The UKHSA Inclusion Health team then discussed and refined these themes with the 10 VCSE organisations to coproduce recommendations that represent a synthesis of 鈥榣ived and learned experience鈥�. The authors include direct quotations from engagement reports to illustrate main points. This project did not require ethical approval as this was not research but was collecting insights to improve the quality of programmes and services.

Findings

Knowledge and perceptions of important infections and vaccines

There was awareness of high risk of infections but mixed awareness of different important infections including:

• tuberculosis
• blood borne viruses
• sexually transmitted infections
• vaccines

Infections and communications about infections were noted to be potentially stigmatising. Some participants were very positive about the benefits of vaccines while others expressed uncertainty and concerns. Several inclusion health groups identified a need for tailored information on infections and vaccinations for their communities. Sex workers and people who have injected drugs reported higher levels of knowledge on infections that particularly affected their communities. Even where knowledge of infections was good, multiple barriers to accessing healthcare and poor continuity of care were highlighted as barriers to vaccination, diagnosis and ongoing management of infections.

Infections were not always seen as a priority given wider health concerns including:

• mental health needs
• risk of violence (particularly for sex workers)
• chronic disease management
• broader access to health care including dental care
• housing
• hunger
• employment
• exposure to environmental hazards including extreme weather and poor air quality (particularly for people with experience of homelessness and Gypsy, Roma and Traveller communities)

The need for integrated holistic health services to address both health protection and wider needs was identified by all groups.

Barriers and facilitators to care

Access to healthcare is critical to the delivery of health protection interventions. All groups identified the need to improve access to healthcare that meets complex needs of inclusion health groups and promotes more positive experiences of care.

Commonly reported barriers included:

• challenges in access to primary care
• stigma and discrimination
• competing needs (such as housing, security and accessing food)
• lack of care continuity
• concerns around confidentiality
• wider legal contexts (such as eligibility for healthcare, fear of disclosure of criminalised activities such as drug use, sex work or irregular migration)
• lack of understanding and training of health professionals in the needs of excluded groups

Facilitators to improve accessibility of services included:

• drop-in services in convenient locations
• outreach
• support to access care
• a focus on building trust (including through peers)
• reassurances on confidentiality of services
• ensuring healthcare workers understood their needs
• providing holistic and integrated people-centred approaches to meet wider needs and to minimise the need for multiple appointments with multiple providers
• care tailored to the needs of individuals and groups
• lived experience input into design and delivery of services

Outreach models

Outreach models have been identified as important by NICE guidance (Integrated Health and Social Care for people experiencing homelessness). Outreach has been used as a means of delivering important health protection interventions. These include the Hep C elimination programme, tuberculosis screening and to improving coverage of vaccines. Participants were therefore specifically asked about their views on this approach.

Most inclusion health groups identified outreach as being important and highly acceptable, particularly if offering integrated services and embedding peers. Perceived benefits included greater reach to socially excluded groups, opportunity for connection, specialist staff and welcoming environments. Outreach was seen to build confidence in people鈥檚 right to health and their confidence in health services. It was viewed as valuable in its own right and as a helpful bridge into wider services. However, if not well-integrated with other services, it was raised there could be potential risk of detachment from mainstream services. Groups also recognised that resource constraints were likely to affect availability. The need to consider location and privacy to reduce any potential for stigma and the importance of consistency in provision were raised. Some people favoured 鈥榓ll-inclusion health approaches鈥�, while others preferred the idea of group-specific services.

Role of peers

There was widespread recognition of the value of peers, who are defined as people with similar lived experience, in service design and delivery to break down barriers and build trust. There was a wide range of roles that peer-workers were identified as being able to support with in relation to service design and delivery. However, some reported worries that peers may not maintain confidentiality. The importance of embedding peers into health services and programmes through strong supporting structures for training, holistic support, employment and career development pathways was raised. VCSEs were noted as having considerable experience in providing this structure and support.

Discussion

Strengths and limitations

Ten VCSE organisations collected rich data and produced reports from a wide range of inclusion health groups on their experiences and views around access to services to support health protection. This offered a good spread of views with over 200 people consulted across the 7 main inclusion health groups. However, as this is a selective sample it cannot be representative of all people in inclusion health groups. Many of the VCSE organisations were peer-led organisations, some of which were also involved in supporting peer roles. To reduce biases, session organisers were asked to include people with lived experience who were not employed in peer roles. The approach did not explicitly address the needs of children of people in socially excluded groups.

Consultation guides helped to standardise the content of engagement sessions but organisations had flexibility in how to run sessions based on their experience of working with different populations, resulting in variation of approaches used. A pragmatic approach to thematic analysis was taken rather than following a theoretical framework. The synthesis was based on identifying themes from reports produced by VCSEs rather than verbatim transcription of sessions. The findings are consistent with those described in wider research, policy and guidance documents (see Annexe 4: additional resources) but offer additional insight into views on health protection issues. The approach also differed from mainstream literature by encouraging participants to express their views on solutions that they thought would address barriers to care.

The coproduction process to develop recommendations involved identification of important components of care expected to improve access from analysis of the reports complemented by UKHSA authors鈥� understanding of the broader literature. The UKHSA Inclusion Health team then discussed and refined these themes with the 10 VCSE organisations to coproduce recommendations that represent a synthesis of 鈥榣ived and learned experience鈥�.

Recommendations: 5 core components of inclusive models

UKHSA identified and refined 5 common components of inclusive approaches to care through further consultation with lived experience representatives of VCSEs: 听

1. Build trust first
2. Provide integrated, holistic, people-centred approaches
3. Build in accessibility to increase engagement and uptake
4. Tailor approaches to increase relevance
5. Embed peer roles

1. Build trust first

Poor prior experience of services had often damaged trust and was an important barrier to care. Building trust was highlighted as of central importance. Approaches included:

• engagement with affected communities to support service design
• having time and continuity to develop relationships
• involvement of peers who understand needs through personal experience
• staff who are trained in the needs of different groups providing culturally sensitive, trauma informed and non-judgemental care
• clear communication that services are confidential

Many reports also highlighted that when established services stopped being provided, this damaged trust in other initiatives.

2. Provide integrated, holistic, people-centred approaches

Although engagement focused on health protection needs, these were often a lower priority than other immediate unmet needs (for example, access to food, shelter, security and income) and other physical and mental health problems. This often resulted in multiple appointments with multiple providers and needing to repeatedly explain traumatic personal histories, all acting as important barriers to care and health protection interventions.

Integrated, holistic, people centred services that were able to address multiple needs were seen as important to meet these needs and remove barriers to care and wider support. This aligns well with plans in the NHS 10 year plan for more integrated and holistic services in neighbourhood health centres particularly for groups with complex needs.

Examples included a one stop shop and mobile models that combine:

• meeting people鈥檚 immediate needs
• provision of health protection and wider health information
• important health interventions that support integration with wider services

Some of these interventions may need additional partnership with primary care or wider health services.

Figure 1. Participant鈥檚 suggestions for integrated care models

Accessible description of Figure 1

Figure 1 shows a 鈥榦ne-stop shop鈥� model for services.

At the centre are the suggested interventions from participants. These include:

• vaccinations
• infection testing
• basic health checks
• treatment of common conditions
• wound care
• GP access
• mental health assessments and access to services
• lung health checks, stop smoking advice and support
• needle exchange
• provision of food

The one-stop shop links to wider health services. These include:

• secondary care
• mental health services
• drug and alcohol services
• dental care
• opticians
• podiatry
• pharmacy

It also links to wider non-health services. These include:

• adult social care
• benefits advice
• legal advice
• domestic violence services
• immigration advice
• VCSE support
• housing support
• family support
• probation
• education

The diagram shows two-way arrows between the one-stop shop and both types of services. This means support can be joined up and people can be referred between services.

3. Build-in accessibility to increase engagement and uptake

Participants suggested a wide range of approaches to increase accessibility of services. The location of integrated holistic services was seen as important, with a preference for these to be in familiar community, non-clinical, discrete and convenient locations and complemented by outreach. Participants suggested locations and approaches to increase accessibility which are described in Figure 2.

Figure 2. Participants鈥� suggestions for locations and approaches to increase accessibility

Accessible description of Figure 2

Figure 2 shows a list of potential community settings for a hub. These include:

• libraries
• community centres
• hostels
• food banks
• soup kitchen
• drug services
• train stations

There is a plus sign between this list and a separate list for 鈥榤obile outbreak or satellite component鈥�.

• bus, vans, cars, bikes and on foot
• multiple locations
• regular 鈥榮et day鈥�
• 鈥榖ase of operations鈥� for outreach staff
• vehicle should provide some level of privacy
• accessible and disability friendly

Approaches suggested by participants to increase accessibility

Participants suggested:

• drop-in services without the need for fixed appointments with flexible opening hours
• outreach was seen as important both in connecting and reconnecting people to services and for provision of important health interventions including screening and vaccination
• rapid testing with same day results were seen as enhancing accessibility, acceptability and onward care opportunities
• staff should be welcoming, trusted, compassionate, and non-judgemental
• people with lived experience working as part of wider teams were widely seen as important to improve accessibility as described in more detail below

4. Tailor approaches to increase relevance

While there were many common needs across different inclusion health groups there were also important differences resulting in a need to tailor approaches to specific groups to increase relevance.

Participants鈥� suggested approaches to increase relevance included:

• specialist knowledge and training of staff so they were knowledgeable about the needs of different groups
• developing tailored information resources including on infections, vaccinations and other issues
• working with people with lived experience to develop these materials to increase relevance and reduce stigma
• having specific days and times for different groups

5. Embed peer-led roles

Embedding peer-led roles in the design, delivery and evaluation of services was recommended to increase acceptability, relevance and quality. Lived experience and peer roles were identified as valuable in building trust, overcoming barriers and improving engagement and quality, addressing power imbalances and providing role models.

It was stressed that peer roles should be adequately resourced and supported with opportunities for career progression. Recruitment principles may need to be adapted for peers. Inclusion health VCSE organisations have expertise in supporting the embedding of peer-led approaches.

Participants鈥� suggested peer roles around supporting access and engagement and delivering services. These include:

• support with initial engagement and accessing services that cover prevention, diagnosis and into treatment
• support with accessing health protection interventions such as vaccinations
• treatment support, including reminding and accompanying to appointments, health service navigation, advocacy and treatment adherence
• support engagement with long-term conditions, for example, HIV, hepatitis B, diabetes, chronic obstructive pulmonary disease (COPD)
• finding people lost to follow up
• delivering care with appropriate training and governance including point-of-care testing and vaccination
• multidisciplinary referral support
• supporting access to wrap around care, for example, housing, benefits, phones, counselling

Participants鈥� suggestions for wider peer-led public health and training roles included:

• health promotion
• disease surveillance, for example, delivering surveys with at-risk populations
• data collection
• lived experience, self-disclosure talks at organisations such as drug and alcohol centres or prisons
• training and sharing with lived experience and non-lived experience staff

Conclusions and next steps

This report provides valuable insights on people with lived experience鈥檚 views on important health protection issues and wider health challenges. It outlines the barriers and facilitators experienced by inclusion health groups when accessing health services. It also covers views on acceptability of integrated outreach models and the importance of peers. It identifies coproduced recommendations for core components of inclusive models of care to address health protection and wider inequalities in inclusion health groups.

The intention is that these findings and the recommendations made will inform action at national, regional and local level to build more inclusive approaches to health protection and better meet the needs of people in inclusion health groups. In UKHSA we are taking this forward through a range of approaches.

Building trust and involvement

Building trust and involvement of people with lived experience to inform our preparedness and response activities through ongoing community engagement. This is both in response to incidents and longer-term health protection needs such as access to vaccines, diagnosis and treatment. This has included working with the VCFSE sector to inform our approach to incidents such as mpox and measles, for example:

• informing our guidance and communications
• shaping longer term policy and practice on areas such as TB

Regional health protection teams also work closely with directors of public health and integrated care boards to support work with groups in local areas.

Strengthening data systems

Strengthening data systems, synthesising evidence and commissioning research will help to better understand multiple health protection needs. It will also help to understand the effectiveness and cost effectiveness of providing integrated and accessible health protection interventions. For example, UKHSA has piloted multi-pathogen testing in prisons and places of detention (PPDs) to better understand prevalence of infection. This has strengthened the evidence base around testing interventions and informed the implementation of guidance on infectious disease screening.

UKHSA also recently published the Health Inequalities in Health Protection report which provided a high-level description of the current state of inequalities in health protection in England through the data, aiming to support targeted and evidence-based strategies and interventions for听longer term change.

Engaging with partners

Engaging with partners can highlight the value of integrated, accessible services to meet health protection and wider needs of socially excluded groups. These partners can include:

• other governmental departments
• wider health system partners
• local authorities
• commercial partners
• the VCFSE sector

Engagement with partners includes piloting and evaluating such integrated approaches where possible.

Working with people with lived experience on peer-led projects

Working with people with lived experience on peer-led projects, to co-produce information resources for specific socially excluded groups. 听For example, vaccine promotion materials co-created by Gypsy Roma and Traveller communities for their communities from design to delivery. Another example is coproduction of information on severe infections in people experiencing homelessness and who use drugs.

A people-centred, systems-based approach is likely to deliver the best health outcomes for those who experience some of the most disproportionate or worst health protection outcomes.

Annexe

Annexe 1: VCSE organisations and reports

These individual organisation reports were developed through funding from UKHSA through a University College London Hospitals (UCLH) commission. These reports do not necessarily reflect the views of UKHSA or UCLH.

A:

Focus: Refugees, people seeking asylum and other migrants in vulnerable circumstances
Their report: Doctors of the World submission to UKHSA National Integrated Inclusion Health Outreach Service

B:

Focus: People in contact with the justice system
Their report: BBV, STI and TB Screening in Prison and Access to Health on Release: Views from Prison

C:

Focus: People with experience of homelessness
Their report: Feedback report by Expert Focus of insights from people experiencing homelessness

D:

Focus: Gypsy, Roma and Traveller communities
Their report:

E:

Focus: People with experience of homelessness
Their report:

F: Gypsy Life

Focus: Gypsy, Roma and Traveller communities
Their report: Research Commission to support development of inclusion health outreach services: Gypsy, Roma and Traveller communities.

G:

Focus: People with lived experience of Hepatitis C including people who use drugs
Their report:

H:

Focus: Sex workers
Their report:

I:

Focus: People subject to modern slavery and trafficking
Their report:

J:

Focus: Sex workers
Their report:

Annexe 2: Consultation guide to VCSE organisations

UKHSA and UCLH National Integrated Inclusion Health Outreach Service Design Project 鈥� consultation guide for engagement workshops, July 2023

Hold multiple user engagement workshops that represent the diverse needs of people with lived experience of inclusion health groups, including those with experience of trying to access testing, treatment or vaccination for priority infections.听

1. Explore awareness of priority infections including tuberculosis, HIV, hepatitis B and C, sexually transmitted infections and vaccine preventable infections
2. Identify barriers and facilitators to accessing diagnosis, treatment and vaccination
3. Explore acceptability of integrated outreach 鈥榦ne-stop shop鈥� diagnostic and vaccination services
4. Advise on appropriate settings for outreach
5. Advise on important components of how the outreach service should be delivered, including the role of peers in improving engagement and uptake of services
6. Advice on the best approaches to supporting referral into treatment and ongoing support
7. Highlight any important relevant issues not addressed above

Inclusion Health populations can include:

• refugees, people seeking asylum and other migrants in vulnerable circumstances, including but not limited to people who are or were subject to modern slavery and trafficking)
• people experiencing homelessness including rough sleepers, those living in hostels and other supported accommodation and those using day centre
• people who use drugs including those who are not engaged with drug treatment services
• sex workers including street sex workers
• Gypsies, Roma and Travellers including those in local authority designated sites and unofficial sites
• people in contact with the justice system including those in custody suites, prisoners, and those in licensed probation premises

These populations often overlap.

Priority or important infections

Inclusion Health populations are at high risk of multiple priority infections and coinfections including:

• tuberculosis
• blood borne viruses (including HIV, hepatitis B and C)
• sexually transmitted Infections
• vaccine preventable infections (including hepatitis B, influenza, COVID-19, pneumococcal vaccine and catch up-immunisations for example, missed childhood vaccinations and tetanus boosters)

Health protection services include prevention (for example, through vaccination and harm reduction approaches such as promoting safer injecting and consumption and opiate substitution therapy), early diagnosis (through targeted testing) and effective engagement with treatment are vital to improve health outcomes and reduce transmission.

Annexe 3. Methodology of VCSE consultations

Annexe 3 is a separate PDF. Go to the homepage and select 鈥楢nnexe 3. Methodology of VCSE 肠辞苍蝉耻濒迟补迟颈辞苍蝉鈥�.

If you need an accessible version of Annexe 3, contact healthequity.queries@ukhsa.gov.uk

Annexe 4: Additional resources

• NHS England (NHSE). 2025
• NHSE. 2023
• NICE guideline NG214, 2022
• NICE systematic review. 听 NICE 2022
• Luchenski and others. Lancet 2018: volume 391, issue 10,117, pages 266-280
• Johnson L and others. Lancet Public Health 2025
• Journal of Public Health 2015: volume 38, issue 2, e125-132
• UKHSA. Tackling TB in inclusion health groups: toolkit for a multi-agency approach 2024
• HCV Action Hepatitis C Elimination Maintenance Strategy Group, July 2025
• UKHSA. Supporting vulnerable people before and during hot weather: people experiencing homelessness and sleeping rough 2024