Work packages

Collecting evidence

Objectives:

• To collect evidence on health system determinants of low vaccine uptake and high vaccine uptake among underserved groups in Europe.
• To collect evidence on what interventions work to improve vaccine uptake in these groups, based on the grey and published literature.
• Generate knowledge to serve as a basis for interventions and guidance to improve vaccine uptake among underserved groups in Europe.

WP2 will collect evidence on health system determinants of low vaccine uptake (barriers), and high vaccine uptake (enablers) in the literature as well as through a series of qualitative studies among five underserved groups in four European countries:

(1) the migrant community in Greece (focus on MMR and HPV),

(2) Turkish females and (3) Moroccan females in the Netherlands (focus on HPV),

(4) the Ukrainian minority in Poland (focus on MMR and HPV) and

(5) the Roma community in Slovakia (focus on HPV).

At the same time, we will identify and describe enablers to vaccination from three communities with uncommonly high vaccine uptake. These are:

(1) the Somali community in Finland,

(2) the Arab community in Israel, and

(3) the Bangladeshi community in the United Kingdom.

By focusing on eight different underserved communities, the results will provide an increased understanding of the health system determinants of low and high vaccine uptake in their specific contexts that will vary in terms of geography, size, wealth, health systems, culture and vaccination law.

Deliverables:

• D2.1 :A systematic review of the literature on barriers and enablers to vaccination uptake among underserved groups in Europe.
  The focus will be studies published primarily in English language in or after 2005. The search strategy will combine the following concepts: population age (children and young people), geography (the European region), population group (underserved communities) and type of barriers and enablers (health systems focused).

Fourth quarter of 2022

• D2.2: Five qualitative studies describing barriers and enablers to vaccination for each of the five selected underserved groups:

1) The migrant and refugee community in Greece (with a focus on MMR and HPV vaccines)
2) Turkish adolescent females in the Netherlands (focus on HPV)
3) Moroccan adolescent females in the Netherlands (focus on HPV)
4) The Ukrainian migrant community in Poland (focus on MMR and HPV)
5) The Roma community in Slovakia (focus on HPV)

Fourth quarter of 2022

• D2.3: Three qualitative studies describing barriers and enablers to vaccination for each of the three underserved communities with uncommonly high vaccine uptake:

1) The Somali Community in Finland
2) The Arab Israeli community in Israel
3) The Bangladeshi community in the United Kingdom (specifically in London)

Fourth quarter of 2022

WP2 Leader: Bar Ilan University (BIU).

Development or adjustment of tailored interventions

Objective: to have tailored interventions to increase child and adolescent vaccine uptake in underserved communities. More specifically:

• To assess to what extent the available (national and international) interventions are transferable from the primary context to the target context (i.e. underserved communities)
• To adapt available (national and international) interventions so that they better reflect the culture and wishes of the target community (i.e. underserved communities)
• To develop new interventions for underserved communities for which no intervention (national and international) is yet available

The transferability assessment of these promising enablers and interventions follows the PIET-T model (Process model for the assessment of transferability) ¹Schloemer, T., & Schröder-Bäck, P. (2018). Criteria for evaluating transferability of health interventions: a systematic review and thematic synthesis. Implementation Science, 13(1), 88. The PIET-T model of transferability includes 44 criteria, covered by four overarching themes, which influence transferability of health interventions: The population (P), the intervention (I), and the environment (E) represent 30 conditional transferability criteria. The transfer of the intervention (T) represents 14 process criteria for transferring the intervention to the target context. Transferability (-T) depends on the dynamic interaction of conditional criteria in the primary and target context as well as on the process of transfer.

The first task of WP3 is to assess the transferability of promising interventions identified and selected in WP2 (D2.4). Based on the results of the transferability assessment and the data collection on the need for adaptation among stakeholders via focus groups, we will determine outcome-relevant criteria of the community, the environment and the intervention, which could be empirically measured in the further process. We will also provide recommendations on the comparability of the outcome measures between primary and target context.

The second task of WP3 is to adjust or adapt interventions that: 1) have been shown to be effective, 2) have been implemented and evaluated in a real world-setting and 3) are – in principle and after potential adaptations – transferable from the primary to the target context.
In case the results from WP2 do not show effectiveness, or our transferability assessment is not favourable, the third task of WP3 is to develop new interventions to address specific barriers to vaccine uptake in the target communities. To do so, we will use the Delphi-technique to determine - per underserved community - the most important health system barriers to address. To develop interventions that address as many health system barriers as possible, we will link the selected health system barriers to concrete and desirable behaviours of professionals and policy makers within the health system, and on deriving objectives. We will formulate the objectives to be as specific and measurable as possible so as to tailor the intervention to the heart of the problem and to be able to evaluate the effects of the intervention later.

Finally, we will integrate the results into a coherent intervention with an overall description of the interventions and its objectives and target groups. Further elaboration of the implementation plan will take place in WP4.

Deliverables:

• D3.1: A report with an assessment of the likelihood of successful transfer of vaccine uptake promoting interventions, naming barriers and facilitators for transfer; including indications and recommendations for adaptations of the interventions to better fit the target context and a successful implementation therein.
  Fourth quarter of 2022
• D3.2: A selection of health system barriers to be addressed will be made for each of the five underserved communities.
  Third quarter of 2022
• D3.3: A matrix per intervention will be developed, containing intervention objectives, including the barriers and facilitators to be influenced.
  First quarter of 2023
• D3.4: A provisional list of potential methods and strategies for intervention implementation based on experts’ input, consultation of target communities and the literature review.
  Third quarter of 2023
• D 3.5: Development of coherent interventions
  Third quarter of 2023

WP3 Leader: University Medical Center Groningen (UMCG), the Netherlands

WP3 Co-Leader (Tasks 3.1, 3.2): Maastricht University

Implementation and Evaluation of tailored interventions 

Objective: to have implemented and evaluated interventions. More specifically:

• Develop implementation plans that emphasise co-creation and collaboration
• Develop a monitoring plan that will facilitate implementation of the actions, assessment of agreed indicators and visibility of the implementation processes.
• Measure and evaluate the implementation of tailored interventions and assess their scalability

To guide the implementation of selected interventions (based on work in WP2 and WP3), an implementation plan will developed in each setting in close collaboration with members of the target communities, healthcare professionals, logistic personnel, and policymakers. The plan will outline the implementation details, including where, which target group(s), which activities to be implemented, a detailed timeline, and risks and contingency planning. It will also contain information about tasks and responsibilities of the stakeholders involved in co-creation and collaboration on the implementation.

Along with the implementation plan, a monitoring and evaluation plan will be developed in each setting, taking into consideration both specific characteristics of the intervention and local context, as well as core common indicators to be measured related to the project objectives.

The Dynamic Learning Agenda (DLA) ²https://knowledgehub.fit4food2030.eu/resource/dynamic-learning-agenda-dla/ tool will be used in all settings to ensure effective monitoring of the implementation of the intervention and to identify and act upon challenges faced during the implementation. This tool has been developed as a reflexive monitoring tool in system innovation changes and allows stakeholders to learn and evaluate while implementation occurs. It will foster co-creation and collaboration by giving a voice to all stakeholders who can put their challenges faced on the agenda for dialogue and possible solutions.

Common indicators to be measured by all interventions through quantitative research are:

• Increase of MMR and HPV vaccinations among the target groups to be closer to the country average compared to baseline (pre-post);
• Increase of knowledge concerning MMR and HPV vaccinations among the target group (healthcare professionals compared to baseline (pre-post);
• Satisfaction of the target group (underserved communities and healthcare professionals) with the intervention (80%);
• Improve access to vaccinations by addressing identified system barriers (number of barriers addressed).
• Cost-effectiveness analyses of interventions will be performed according to existing country-specific guidelines for performing cost-effectiveness analyses.

Deliverables:

• D4.1: Preparation of the implementation plans including monitoring and evaluation frameworks (1 for each intervention)
  Fourth quarter of 2023
• D4.2: Implementation reports including monitoring/evaluation results (quantitative, qualitative and cost effectiveness), one for each community where the intervention is implemented.
  Fourth quarter of 2025
• D4.3: Overall report presenting key findings from individual implementations.
  First quarter of 2026

WP3 Leader: Astiki Mikerdoskopiki Etaireia Prolipsis (Prolepsis), Greece

WP4 Co-Leader (Task 4.3.2): University Medical Center Groningen (UMCG), the Netherlands

Guideline development 

Objective: To produce evidence-based guidelines, based on the outputs of WPs 2, 3, and 4, that complement existing guidelines and address equitable access to vaccination across Europe, based on the lessons learned from the implementation and evaluation of interventions.

WP5 aims to ensure that the evidence generated through the lifetime of the project (including generalisation of specific examples and case studies) is available to any public health actor who is mandated or interested in decreasing health inequalities by improving access to vaccination services for underserved groups. The guidelines will be articulated around the WHO health systems building blocks and target the relevant levels of the healthcare system (national, subnational and facility level). It will incorporate an action framework to ensure that the guidelines are implementable and relevant to the operational level in each country.

The evidence required to support the guidelines will have largely been collected or generated through work packages 2-4, focusing on what are the health systems barriers and enablers to vaccination in underserved communities, and how to overcome them. The first task will be creation of guidelines that are applicable to all EU countries. We will ensure that the guidelines produced are aligned with, and complementary to, existing and planned guidelines on the topic, such as the WHO Tailoring Immunisation Programmes (TIP) guidelines and the regional immunisation equity guidelines.

Once the guidelines have been developed, an action framework will be generated, applicable to all three levels targeted by the guidelines (national, subnational and facility). This ensures hat the guidelines will be implementable and relevant to the operational levels in each country. Finally, the guidelines and action framework will be made available online as an interactive tool and widely promoted.

The team will convene a consultation group to support the development of the guidelines. The consultation group will consist of representatives from vaccine programmes working at the national, subnational and facility level in the seven countries involved in the project, representatives from key European Public Health Institutions (WHO EURO, ECDC, EUPHA), two lay members representing underserved communities in Europe and public health practitioners representing the three levels targeted by the guidelines.

Deliverables:

• D 5.1: The creation of guidelines that will be applicable to all EU countries and will enable them to remove health systems barriers to immunisation among underserved communities.

The guidelines will be accompanied by:

• D 5.2: Action framework applicable to all three levels targeted by the guidelines (national, subnational and facility) to ensure that they are implementable and relevant to the operational level in each country
• D 5.3: Interactive tool - an online version of the guidelines and action frameworkFirst quarter of 2026

WP5 Leader:UK Health Security Agency (UKHSA)

Strengthening Education and Knowledge on Immunisation (SEKI)

Objectives:

• To develop a shared European platform for healthcare professionals and (para)medical to access vaccine-related education and training activities
• To create a shared infrastructure (website/app) and social media incentives encouraging healthcare professionals and (para)medical students to improve their knowledge on immunisation, vaccine communication, immunisation safety, and vaccine preventable diseases with a special focus on high-risk and under-vaccinated communities.
• To integrate lessons learned from RIVER-EU research in order to update vaccine-related education and training activities to consider localized health systems factors such as access, acceptability, and quality of vaccine services.

Research and surveys conducted under the EU Joint Action on Vaccination (EU-JAV) and by the European Coalition for Vaccination identified a lack of coherent and high-quality educational content on vaccination. Vaccine education, as delivered to healthcare professionals in pre- and in-service training is perceived as fragmented and confusing, as compared to other subject matters, where curricula are more systematic. The complexity of the topic – and rapidly evolution in the field of vaccinology – makes it increasingly difficult for health care professionals to keep up-to-date. This issue requires a coordinated approach to vaccination training, including vaccine communication.

WP6 will develop the SEKI Platform (Strengthening Knowledge and Education on Vaccination, www.seki.eu) will develop a ‘One-stop-shop’ for healthcare students and professionals to access materials easily. The platform was initiated in 2019 by the Vaccine Safety Initiative in collaboration with the European Academy of Pediatrics (EAP) on behalf of the EU Coalition for Vaccination and created as a result of a project involving young parents, physicians, and medical students, at the School of Design Thinking in Potsdam, Germany.

The platform will monitor use and uptake regularly. Users will be encouraged to keep using the platform to build a life-course approach to vaccine education covering key aspects such as vaccine communication, immunisation safety, and vaccine preventable diseases with a special focus on high-risk and under-vaccinated communities. Ongoing user testing will (1) utilize feedback from all users that can be easily submitted through the website or app and (2) study the demographics of the user base in order to determine what subgroups of potential users may be missed with this approach.

Pre and post testing of users will measure the growth of users’ knowledge, both related to general immunisation facts (initial content) and more complex facets of immunisation including local health systems, access, and inequalities. Modules for pre-post testing will be made available to provide structure. Secondly, the opportunity will be established for users to begin collecting credit (training points) over time and to store them in the SEKI system.
Lastly, a SWOT (Strengths/Weaknesses/Opportunities/Threats) analysis will be performed by SEKI members in collaboration with the European Board of Paediatrics to identify any gaps and deficiencies and areas that need additional coverage.

Deliverables:

• D6.1 Establishment of an online system with up-to-date educational content for healthcare workers and medical students, which presents the possibility to register for educational activities and to collect training points once the platform has passed the testing phase.
  Second quarter of 2023

• D6.2 Report based on lessons learned in RIVER-EU and exclusive Strengthening Education and Knowledge on Immunisation (SEKI) training materials dedicated to cultural competency working on migrant and minority health, as well as online platform sustainability.
  Second quarter of 2026

WP6 Leader: Vaccine Safety Initiative

Dissemination and exploitation

Objective: to ensure maximum RIVER-EU visibility and the sustainability of its results beyond the lifetime of the project. More specifically:

• To develop a detailed dissemination and communication plan with a distinct visual identity for the project;
• To communicate RIVER-EU objectives, activities and results to all relevant target audiences, including the general public, policymakers, and healthcare professionals;
• To ensure effective exploitation and long-term sustainability of RIVER-EU’s results and learnings.

The RIVER-EU communication timeline will mark the schedule and direction of dissemination activities. The plan will closely follow project activities across 60 months of implementation, aligning with the phases of the project when major deliverables are released.

- Phase 1: Consolidating the knowledge base (WP 2-3)

- Phase 2: Implementation (WP4)

- Phase 3: Sustainability (WP5-7)

During the Phase 1, primary research and initial outreach to relevant stakeholders will take place, increasing consortium knowledge and raising awareness of the project and its aims with targeted communities. The different channels of communication will be established and strong networks in communities will be mapped and mobilised to prepare for the intervention design and implementation phases. Links will be made with other relevant projects, with local community leaders, and EU and Member State actors with relevant competencies in vaccination in the targeted communities.

During the Phase 2, WP7 will support implementing partners in the five pilot communities (in four countries) with appropriate communications measures and materials to conduct pilot implementation and evaluation. Continuous communication efforts will increase the visibility of pilot actions and help to maintain the commitment and motivation of participants.

The final phase focuses on guaranteeing the sustainability of RIVER-EU’s results and increasing its impact. During this period, the results of the implementation and evaluation will be used to develop key deliverables such as the guidelines for policy makers (WP5) and educational materials for healthcare professionals (WP6) to increase low vaccine uptake. Important conclusions about transferability and scalability of the approaches will also be reached and shared with a broad audience of relevant decision makers and actors in Europe and beyond.

Deliverables:

• D7.1 Dissemination and Communication Plan and visual identity, and website launch.
  Third quarter of 2021
• D7.2 A report on the engagement of target groups will be produced in M24, to assess the need for changes in strategy.
  Second quarter of 2023
• D7.3 Exploitation plan.
  Second quarter of 2025

WP7 Leader: EuroHealthNet

WP7 Co-Lead: Connaxis