Greece

Target communities: Migrants and refugees.

Vaccine(s): Measles, mumps, and rubella (MMR) and Human Papilomavirus (HPV).

Description of the target community

According to UNICEF, in June 2019 an estimated 29,000 migrant children were present in Greece. The migrant/refugee crisis which started in 2015 continues to date with frequent escalations of flows occurring such as ones originating from Turkey. For instance, in March 2020 thousands of migrant refugees gathered on the Greek/Turkish land border seeking entrance into Europe. Since then and due to the COVID-19 pandemic this crisis has temporarily subsided. However, the flows show another increase as summer months draw near. According to 2019 data, about one out of three refugees in Greece are children while the female: male ratio is 1:2 (UNHCR, 2019). The majority of children are from Afghanistan (45,2%) and Syria (22,8%).

Vaccine uptake

Until March 2017, vaccination of migrant/refugee children was mainly performed by non-governmental organisations (NGOs) under the coordination of the Greek Ministry of Health (MoH). According to the latest data, in 2018 approximately 80% of the children among the migrant/refugee community 1-14 years old had received the first dose of MMR vaccine, while 45% received the second one. Among children aged 0-4, almost 50% had been vaccinated with the first dose of MMR and below 25% with the second.1Mellou, K., Silvestros, C., Saranti-Papasaranti, E., Koustenis, A., Pavlopoulou, I. D., Georgakopoulou, T., … & Terzidis, A. (2019). Increasing childhood vaccination coverage of the refugee and migrant population in Greece through the European programme PHILOS, April 2017 to April 2018. Eurosurveillance, 24(27). As HPV vaccination is not available in Greece for refugee/migrant children, no vaccination rates are available for this vulnerable community. The Mig-HealthCare project – Minimize health inequalities and improve the integration of vulnerable migrants and refugees into local communities is a 3-year EU project coordinated by RIVER-EU consortium partner PROLEPSIS. Within the project a survey was conducted in 10 EU MS among 1300 refugee/migrants over the age of 18 years old. 73.3% of migrants (874 out of 1,193 valid answers) did not have a vaccination card (26.7% do so). Specifically, for measles 13% of the sample responded that they had been vaccinated against measles, 16% said they did not know while 70% had not received vaccination for measles.

Contextual factors:

The 29,000 migrant and refugee children present in Greece are spread over several locations across the country in different living circumstances: 60% live in urban areas (apartments, hotels, shelters for Unaccompanied and Separated Children (UASC, self-settled, etc.), 26% live in accommodation sites and 1% live in safe zones, and a further 13% are in Reception and Identification Centers. Being one of the countries on the outside borders of Europe, Greece has a great influx of migrant refugees seeking access to Europe. This influences the number of migrant refugee children present in the country a great deal and as long as one of the routes to Europe is via Greece, the vaccination issue among refugee children will be present.

Health system barriers:

With regard to Greek migrants/refugees, including children, young people and their parents, there is little relevant data collected about them entering the health and care system. There is a lack of documentation of vaccination and medical history of Greek migrants. 2Hargreaves Sally, Nellums Laura B, Ravensbergen Sofanne J, Friedland Jon S, Stienstra Ymkje, on behalf of the ESGITM Working Group on Vaccination in Migrants. Divergent approaches in the vaccination of recently arrived migrants to Europe: a survey of national experts from 32 countries, 2017. Euro Surveill. 2018;23(41):pii=1700772. Migrants and refugees in Greece experience barriers in communication with healthcare professionals due to intercultural communication difficulties.3www.euvetcare.eu/sites/default/files/O1_Review%20of%20existing%20training%20opportunities_13%2012%202019_Final.pdf  Healthcare professionals who are trained on provision of health care to culturally diverse patients are able to provide vaccination services to an increasing number of culturally and linguistically diverse parents and their children, leading to improved service delivery and enhanced access to services. Until recently, migrants/refugees were issued with a Social Security Number (AMKA) which enabled them to access health care in Greece. This has been suspended, however, due to a change in government. In January 2020 the Ministry of Migration and Asylum decided to provide migrants/refugees who applied for asylum with a provisional social security number. Provisional Insurance and Health Care Number (PAAYPA) is not the same as the Social Security Number (AMKA). PAAYPA ensures the asylum seekers’ access to healthcare, social security and the labor market following the submission of their application. If their application is accepted PAAYPA will turn into AMKA, while in case of rejection PAAYPA will be automatically deactivated. Last but not least, migrants without documents may be discouraged from accessing government-associated health services, because of their links with immigration authorities. The Mig-HealthCare project revealed that in 10 MS during their interactions with healthcare services 60.1% of migrants/refugees stated that they needed translation always or most of the time, 61.0% were helped by a professional, 15.3% by a family member and 7.9% by nobody.

Addressing heath system barriers to HPV and MMR vaccine uptake

The piloting interventions planned for implementation in Greece aim to help address the most significant and feasible health system barriers to uptake of human papillomavirus (HPV) and measles, mumps, rubella (MMR) vaccines in migrants and refugees. These have been identified by local stakeholders (community members and healthcare professionals) and include: inadequate skills and training in healthcare professionals, limited information delivery, lack of awareness-raising initiatives, language difficulties, and insufficient coordination of health services. A notable finding from the FGDs conducted as a prat of the planning of the intervention, is that the community trusts and prefers that vaccine information comes from health professionals, and would feel more comfortable with a member from their community there to accompany and support the professional. To help tackle these challenges, we are implementing a 2-component intervention: recruiting and training health professionals and promoters who will deliver educational programmes in schools and relevant local migrant associations.

MOST SIGNIFICANT BARRIERS

inadequate skills and training in healthcare professionals

limited information delivery

lack of awareness-raising initiatives

language difficulties 

insufficient coordination of health services

Health professionals and promoters

 
Recruitment of health professionals and promoters

Health professionals (doctors) will serve as the primary source of vaccine education delivery, as they are highly trusted from the migrant community to deliver health information. Health promoters, ideally from migrant backgrounds and bilingual in Greek and other migrant languages, are trained community members who will serve as advocates, supporting the health professionals in communicating the importance of HPV and MMR vaccination among migrant communities. Working in collaboration with similarly trained healthcare professionals, they will conduct educational sessions, equipping adolescents and their parents with the knowledge needed to make informed decisions about their health.

Health professionals’ and promoters’ training

The training materials for the health professionals and health promoters vary in complexity, but the content remains consistent. It covers medical and epidemiological aspects of HPV and MMR-related diseases, along with the pros and cons of vaccination, and practical details on how these immunisations are organised within the Greek National Immunisation Programme. Additionally, the training delivers health communication skills and a culturally sensitive approach so that health promoters and professionals are able to facilitate trust building and gain a better understanding of cultural beliefs and practices that may impact vaccine reluctance in these communities. This comprehensive training will equip health professionals and health promoters with the necessary knowledge and skills to successfully engage with diverse audiences.

Educational programmes in the community

 

Defining target groups for educational sessions

Following the training of health promoters, they will arrange educational sessions on HPV that cater parents or legal guardians of adolescent boys and girls aged 9-18 and the respective adolescents who are eligible according to our study protocol. Separate sessions are provided for each group to ensure tailored education, while also addressing cultural sensitivities by conducting separate courses for boys and girls. The target group for MMR sessions are adolescents who have 0–6-year-old siblings or a pregnant mother and their parents or legal guardians. These MMR sessions will also be conducted separately (for adolescents and parents/legal guardians) to ensure specific needs are met.

Educational content and settings

These educational endeavours will take place in inclusive settings, including multicultural schools and various local migrant associations to ensure accessibility of information to a larger audience. All education sessions are delivered in Greek or English (based on participants’ preferences), with written materials provided in migrants’ main languages, employing simple language to make the information as easily understandable as possible for the target population. The health promoters deliver the sessions and are supported by health professionals who are on hand to help answer any technical or medical questions.
Following these sessions, health promoters will continue to offer support, providing vaccine reminders and assistance with navigating the healthcare system. On-demand appointments with healthcare professionals will also be available for those seeking personalised assistance.

Quality assurance

Prior to the vaccine education delivery sessions to the migrant community, health professionals and promoters will undergo a qualitative assessment of their presentation with Prolepsis to ensure all necessary information is communicated in a digestible and accessible way. Furthermore, to evaluate the effectiveness and quality of the trainings and educational sessions, pre- and post-questionnaires will be utilized, enabling implementers to assess the impact on participants’ knowledge and satisfaction. This feedback will inform ongoing improvements, ensuring that we effectively meet the diverse healthcare needs of our communities.

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