The Netherlands

Target communities: Turkish and Moroccan community

Vaccine(s): Human Papilomavirus (HPV)

Description of the target community

Stateline data shows 13.872 Turkish and 19.163 Moroccan girls (10-15 years of age) are residing in The Netherlands in 20191opendata.cbs.nl/#/CBS/nl/dataset/70787ned/table?ts=1584701163163 first- and second-generation migration background women 0 to 20 years old . They are first- and second-generation migrants, which means that they are born abroad (1st generation) or in the Netherlands (2nd generation) and have at least one parent who was born abroad.2www.cbs.nl/nl-nl/faq/specifiek/wat-verstaat-het-cbs-onder-een-allochtoon- Many of them came in 1960s settling in small towns. Now they are living throughout the country, but mostly in four biggest cities of the Netherlands.

Vaccine uptake

Although the HPV vaccine uptake is currently unknown in the target community, there are sufficient signals to suggest that the coverage is lower than in the national population. For example, participation in the MenACWY vaccination program is less frequent when parents of adolescents were born abroad (52% Morocco to 88% the Netherlands)3Study data not published yet. In addition, Rondy et al (2010) shows in a study for a HPV catch up campaign in 2009 that girls with both parents born in Turkey or both parents born in Morocco have substantially lower HPV vaccine uptake (respectively 37% (Turkish girls) and 24% (Moroccan girls)), than girls with both parents born in the Netherlands (51,8%). The same results can be seen for girls with one parent born in Turkey (44%) and for girls with one parent born in Morocco (36,3%)4Rondy, M., Van Lier, A., Van de Kassteele, J., Rust, L., & De Melker, H. (2010). Determinants for HPV vaccine uptake in the Netherlands: a multilevel study. Vaccine, 28(9), 2070-2075..

Contextual factors:

Within the Netherlands, Turkish and Moroccan girls are less likely to go to higher secondary education and are more likely to drop out without a secondary-school certificate.5www.cbs.nl/nl-nl/achtergrond/2018/47/onderwijs These girls are also more likely – compared to their Dutch counterparts – to experience multiple other problems, like internalizing and externalizing behavioral issues and problems within their homelife and the life outside of the home.6www.verwey-jonker.nl/doc/jeugd/Gemeentelijk%20beleid%20voor%20Marokkaans-Nederlandse%20jongeren_2667B.pdf 7www.kis.nl/sites/default/files/bestanden/Publicaties/emotionele-problematiek-turks-nederlandse-meiden.pdf Also, language barriers still play a role in this group. Parents do not always have enough language skills to understand the information provided on HPV vaccinations.

Health system barriers:

Many Turkish and Moroccan adolescent girls and their parents have negative beliefs and attitudes about HPV-vaccine safety and effectiveness and the conviction that HPV can be extremely harmful, which lead parents and female adolescents to refuse or delay vaccinating for HPV.8Van Lier E, Geraedts J, Oomen P et al. Immunisation coverage and annual report national immunisation programme in the Netherlands 2017. RIVM report 2018–0008., (2018). 9Rondy M, Van Lier A, Van de Kassteele J, et al. Determinants for HPV vaccine uptake in the Netherlands: a multilevel study. Vaccine. 2010;28(9):2070–2075. The ability of the Dutch health system to address the HPV vaccination beliefs and attitudes of Turkish and Moroccan female adolescents and their parents depends largely on the knowledge, skills, motivation and deployment of the healthcare professionals responsible for organizing and delivering the vaccination services and on the readiness of the health system to deliver vaccination services to specific communities. Service-specific readiness refers to the capacity of health facilities to provide the vaccination service, measured through for example trained staff and for intrapersonal and cross-cultural communication guidelines.10Gefenaite G, Smit M, Nijman HW, et al. Comparatively low atten-dance during human papillomavirus catch-up vaccination among teenage girls in the Netherlands: insights from a behavioral survey among parents. BMC Public Health. 2012;12(1):49811Van Keulen HM, Otten W, Ruiter RA, et al. Determinants of HPV vaccination intentions among Dutch girls and their mothers: a cross-sectional study. BMC Public Health. 2013;13(1):111.12Hofman R, van Empelen P, Richardus JH, et al. Predictors of HPV vaccination uptake: a longitudinal study among parents. Health Educ Res. 2013;29(1):83–96.

Addressing health system barriers to HPV vaccine uptake

The interventions that will be implemented in the Netherlands target health system barriers to Human Papillomavirus (HPV) vaccination in people with a Turkish or Moroccan migration background. These interventions are developed through Participatory Action Research (PAR) that involves and engages key stakeholders like community members, academics, and professionals. This co-creative process has revealed that these health system barriers are similar in both communities, and include lack of information delivery, insufficient awareness raising initiatives, inadequate healthcare professional training, language barriers, and inaccessibility. To overcome these, two interventions have been proposed: 1) organising educational programmes for the communities led by trained health promoters and professionals 2) offering an accredited online course on HPV vaccination for healthcare professionals, focusing on reaching communities build of members with a Turkish or Moroccan migration background in the Netherlands.

MOST SIGNIFICANT BARRIERS

lack of information delivery

insufficient awareness raising initiatives

inadequate healthcare professional training

language barriers

inaccessibility

Intervention 1: community-centred education on HPV vaccination

Training

Initially, health promoters will receive comprehensive training through presentations, while healthcare professionals will be trained via an e-learning course. Health promoters comprise motivated bilingual individuals with a migration background, proficient in both Dutch and either Moroccan-Arabic or Turkish. The eligible healthcare professionals for this initiative are those operating within primary healthcare settings, including nurses and general practitioners. These training sessions are designed to enhance understanding of HPV and HPV vaccination, familiarise participants with the organisation of the National Immunisation Programmes related to this vaccine, improve communication skills, and incorporate a culturally sensitive approach. Furthermore, the training addresses common beliefs and perceptions about HPV vaccination prevalent within the target communities. To ensure a culturally sensitive approach, both female and male educators will be engaged, with female health promoters tasked to educate female participants and male health promoters to educate their male counterparts.

     
Education
Identifying the target population

Upon completion of training, health promoters alongside healthcare professionals will conduct tailored educational sessions. The target audience includes parents or legal guardians of vaccine eligible children aged 10 to 14 years old who have not received HPV vaccination yet and have a Moroccan or Turkish migration background. Additionally, boys and girls within the community who reached the age of 14 without being vaccinated against HPV will be included.

Educational content and settings

Our programme delivers education on HPV and HPV-vaccination, fostering discussion on beliefs and understandings around HPV(-vaccination). Parents will learn how to discuss HPV vaccination with their children, and vice versa. Sessions will accommodate participants’ language preferences, being conducted in either Dutch, Turkish, or Moroccan-Arabic. Distributed written materials will be translated accordingly using easy to understand wording. We focus our interventions on provinces where sizable Turkish and Moroccan communities reside, and HPV vaccine uptake is low. The sessions will occur in familiar neighbourhood sites such as community centres, schools, health centres, or religious institutions.

 
Navigation

Following educational sessions, researchers from the University Medical Centre in Groningen (UMCG) will serve as navigators and contact participants. They will Inform them when opportunities arise to receive the HPV-vaccination, assist in finding their way to get vaccinated, and answer any questions. Contact methods, like phone calls or text messages will be based on preferences and local stakeholders’ advice. Follow-ups will occur one week and three months after the sessions.

Intervention 2: nationwide HPV training for healthcare professionals

The aim of this intervention is to train healthcare professionals nationwide. Doctors, nurses, and health promotion/social workers will deepen their knowledge on HPV and HPV vaccination, organisation of the National Immunisation Programmes related to this vaccine and learn how to deliver tailored care and effectively communicate vaccination information. Hopefully, this will ensure that the information provided to Turkish and Moroccan migration background in the Netherlands matches their cultural, religious, and contextual needs and preferences. To achieve this, a two-hour accredited e-learning course will be provided, focusing on HPV vaccination with a specific emphasis on reaching people with Turkish and Moroccan migration background in the Netherlands. The content of the online course mirrors that of the training in the first intervention but delivered on a larger scale, targeting healthcare professionals across the country. Our project is working closely with the National Institute of Public Health and the Environment (RIVM) to develop the material for training and to assist in disseminating it. This collaboration ensures that the training becomes an official programme endorsed by the RIVM and will continue to be available also after the project ends.

EVALUATION

Both interventions will evaluate participants’ knowledge, attitudes, and skills before and after the sessions using pre- and post-questionnaires. Additionally, community members’ intention to get vaccinated will be assessed immediately after the intervention and again three months later. To ensure continuous improvement, feedback and satisfaction levels will be sought throughout this process from all participating members.

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