RIVER-EU webinar summary report

Improving immunization equity

In the context of the annual European Public Health Week, RIVER-EU organised a webinar on 17 May to present its work one year after the project kicked off. A group of project partners spoke about their preliminary research findings from focus groups and personal interviews with healthcare professionals, adolescents, and their parents. They each described barriers and enablers to (HPV and/or MMR) vaccination for five RIVER-EU target groups, highlighting how to strengthen the bridges between the community and the healthcare system. Some of the most important points are captured below:

1. The marginalized Roma community in Slovakia, Dr. Daniela Fiľakovská Bobáková, Pavol Jozef Safarik University, Slovakia

Out of approximately 440 000 Roma in Slovakia, more than half live in marginalized communities characterized by spatial and social distance from the general population. Roma living in marginalized communities often experience discrimination, intergenerational poverty, and limited access to education, employment, housing, and various types of services including health care. These circumstances are reflected in health inequalities between Roma and the majority population. Read more about the vaccine uptake, contextual factors and health system barriers faced by marginalised Roma communities in Slovakia here.

How to strengthen the bridges between the community and the healthcare system?

  • The health mediation programme, “Healthy Regions,” supported by the Ministry of Health employs around 300 Roma health mediators who work in underserved communities. They are key to raising awareness and helping people overcome barriers to access health care.
  • Awareness of HPV vaccination should be brought into the community via the existing network of Roma health mediators. The mediators should be trained and equipped with culturally and linguistically appropriate printed materials. Educational sessions for mothers in community centres and for adolescents at schools should be organised to help close gaps in vaccine coverage and uptake.
  • These measures must also be underpinned by critical legislative changes to make vaccination services more user friendly.
    • Firstly, the age group that receives the HPV vaccine covered by the health insurance should be widened from one year window to include 9–15-year-olds, and simplify the way that the vaccination is organised. Currently, HPV vaccination is not free outside of the one year window at age 12 (for boys and girls).
    • Consider introducing compulsory vaccination against HPV
    • Increase the capacities of health care providers to “catch” marginalised communities.
2. The Ukrainian migrant community in Poland, Prof. Maria Ganczak, Vice-President, Infectious Disease Control Section, EUPHA; Dept of Infectious Diseases, University of Zielona Gora, Poland

In 2019, 212 730 people from Ukraine were registered as migrants in Poland. However, analysis of mobile telephone use in 2018 indicated that the true number of Ukrainians residing in Poland was much higher, in the range of 1.25 million. In 2021, 585,000 people from Ukraine registered as having Polish insurance. Since the start of the Russian invasion of Ukraine in February 2022, more than 6 million Ukrainians have fled their country. Poland has taken in 3.2 million people crossing the frontier so far. Read more about the vaccine uptake, contextual factors and health system barriers in Poland here.

How to strengthen the bridges between the community and the healthcare system?

  • Introduce legislative changes to increase access to health care, including vaccination services for migrants. This should include making HPV vaccination free of charge.
  • Provide GP practices with additional staff to facilitate vaccination consultations. Availability of portable translators would be an asset.
  • Launch vaccination campaigns which target Ukrainian migrants.
  • Community leaders should be educated in vaccination-releated issues, and the the role of front-line healthcare workers in providing vaccine information should also be increased. This will raise health awareness and build trust in vaccines. Translated versions of vaccination-related materials should be provided.
  • Offer web-based education regarding vaccinations in Ukrainian language.
3. The migrant and refugee community in Greece, Mrs. Pania Karnaki, Prolepsis Institute

According to UNICEF, in June 2019 an estimated 29 000 migrant children (aged 18 and younger) were present in Greece. The majority of children are from Afghanistan (45,2%) and Syria (22,8%). There is a lack of documentation regarding vaccination and medical history of migrant children in Greece. Read more about the vaccine uptake, contextual factors and health system barriers here.

How to strengthen the bridges between the community and the healthcare system?

  • Legislation should ensure equal access to all vaccines regardless of person’s legal status.
  • Delivery of vaccination services should be greatly simplified, as it is currently organised between NGOs, schools and shelters working with migrants.
  • Establish Standard Operational Procedures (SOPs), including vaccination registries, which describe and ensure the availability of necessary vaccinations when entering the country. This would enable all relevant vaccinations to be performed upon entry, and avoid opportunistic vaccination only with available vaccines.
  • Communication campaigns in migrant languages would allow for greater interaction (e.g., Q&A), provide procedural guidance, and support culturally appropriate messaging. The campaigns should use safe spaces such as schools, especially for HPV vaccination. Campaigns would ideally target boys – especially unaccompanied minors.
4. Turkish and Moroccan adolescent females in the Netherlands, Dr. Janine de Zeeuw, University Medical Center Groningen (UMCG), the Netherlands

Around 400,000 people of Turkish origin, and about 400,000 people of Moroccan origin live in the Netherlands, mostly around large cities. While the Dutch national HPV vaccine uptake rate is 63% (Annual Report RIVM 2021), girls with at least one parent of Turkish or Moroccan origin had HPV vaccination coverage rates lower than 30% (Munter 2021). Read more about the vaccine uptake, contextual factors and health system barriers facing Dutch adolescent girls of Turkish or Moroccan origin here.

How to strengthen the bridges between the community and the healthcare system?

  • Enhance collaboration with members of these two communities by making new connections with organisations, key persons and community leaders working with (and coming from) the target groups.
  • Organise information sessions on cervical cancer, HPV, and HPV vaccination using materials that are culturally aligned and use simple language.
  • Organise training for health professionals to improve their communication skills to address cultural complexity and the limited health literacy that some community members may have.
5. The Arab Israeli community: An Empowering Example, Dr. Jumanah Essa-hadad, Bar Ilan University (BIU) Israel

21% of Israel’s population is of Arab origin. The Arab Israeli community is generally very young, with 43% of the population below 18 years of age. Only 52% of the Arab community participates in the labor force, mainly due to the low participation of women. Household income is little over half of that of the Jewish Israeli community. Despite being a minority and disadvantaged community, Arab Israelis have high vaccine uptake (MMR and HPV), they are 24% more likely to be vaccinated than Jewish counterparts and thus are an empowering example. Read more about the vaccine uptake, contextual factors and health system enablers here.

What bridges exist between the community and the healthcare system?

  • Childhood vaccines are given in mother-child clinics, which are usually located within Arab-majority neighborhoods and towns, often within walking distance or a short drive. Childhood vaccines also included in the basket of health services, so are given for free.
  • There is an extremely high level of trust among Arab Israeli mothers towards the health system and health care professionals. During the interviews, many mothers shared that they did not think twice about giving their child a vaccine. Another issue that Arab mothers reported as an enabler to vaccination was that the health care nurses were usually Arab, which made them more comfortable as they understood the unique cultural and social characteristics of the population.

The final reflection and conclusions from the session were delivered by Prof. Michael Rigby, Chair of the RIVER-EU Advisory Board, and Emeritus Professor of Health Information Strategy, Keele University.

He noted that health policymakers and practitioners tend to design systems for people like themselves. In other words, they design systems for educated, middle (or upper) class, citizens of their own country. When they do this, then the system may be less responsive or accessible to those who are from a different culture or socioeconomic class. Legislation may also prevent non-citizens from accessing essential services such as routine vaccines.

The speakers made it clear that there is a wealth of good scientific evidence we can use to support better immunisation uptake across Europe. The underlying key message was also similar across all the presentations. The first step is making health information culturally accessible (e.g., translation of health literature and attention to health literacy levels). The second step is understanding what makes the health system itself accessible (e.g., how services should be organised and who should deliver them). This is working well in Israel for instance, but is more challenging when we focus on more temporary accommodation (e.g., of migrants and refugees in cases like Greece and Ukraine). Related to this, better and more integrated immunisation information systems could help reduce barriers and improve our understanding of actual coverage rates.

Some interesting contrasts related to the question of mandatory vaccination, which in many cases is perceived as having negative consequences for vaccine confidence. However, other communities perceive making a vaccine mandatory as an indication of trust (thus, not as a question of conforming, but as a judgement of value).

Prof Rigby asked the audience if health professionals could do more than just build bridges, but actually walk across them into underserved communities. It is the duty of the health professionals to make the effort to be good hosts and help all residents (temporary or permanent) to feel welcome and valued and understood. The concept of positive universalism implies that it is our duty to ensure that all children – regardless of their origins or circumstances – have access to immunization services.

You may also be interested…

During the annual European Public Health Week, there were over 30 events dedicated to vaccination as key prevention strategy. One event that may be of interest to the reader is the symposium co-hosted by the ECDC and the EUPHA Infectious Disease Section which aimed to showcase and celebrate the immense value brought about by vaccines, from the most traditional vaccines to the newest, including in times of a pandemic. The session was chaired by RIVER-EU partner Prof. Maria Ganczak, Dept of Infectious Diseases at University of Zielona Gora in Poland. Other speakers included David Bloom (Harvard School of Public Health), Michele Cecchini (Public Health Division OECD), Mark Jit (London School of Hygiene and Tropical Medicine) and Jonas Sivela, Finnish Institute of Public Health.

You can watch it again here.