From the introduction of new cancer vaccines to tackling measles outbreaks, experts from the World Health Organisation Regional Office for Europe play an active role in supporting vaccination in the region. One of the key elements of modern immunisation programmes is listening to the needs and concerns of communities, and co-designing tailored plans in response.
This was among the key lessons shared at a training seminar hosted by the Active Citizenship Network as part of its VaccinAction initiative. The event discussed how civil society and patient associations can play an active role in enhancing vaccination for people of all ages.
The use of behavioural insights research to understand why people are not following immunisation recommendations is a growing trend in the implementation of vaccine programmes, explained Siff Malue Nielsen, Technical Officer, WHO Regional Office for Europe. From 2020 to 2023, around twenty European countries have engaged with WHO teams to examine barriers to uptake and design interventions.
This research involves interviewing local experts, influencers and communities and – as illustrated by rapid studies conducted during the COVID-19 pandemic – it can provide timely qualitative information on how to boost uptake.
‘Over the past ten years, this approach has become more widely used,’ Nielsen said. ‘During the pandemic, there was a huge appetite from national immunisation programmes to have rapid insights on specific communities. That experience illustrated how this work can be done swiftly to give rapid, real-life data within weeks.’
Preventing measles in Azerbaijan
For example, faced with measles outbreaks in several countries, WHO/Europe teamed up with national authorities to review ways of improving vaccination coverage.
In Azerbaijan, uptake of the first dose of measles vaccine was below 80% in some areas. The target is 95% with two doses.
Researchers interviewed healthcare workers and caregivers to understand barriers and drivers to recommending vaccines. They identified a lack of information and guidance, concerns about vaccine safety, and limited access to vaccination services in rural areas.
Local authorities used these insights to design training programmes for 375 healthcare workers, invited 400 caregivers to an European Immunization Week event, and worked with 167 community leaders to enhance their vaccine knowledge. In a single day, 335 children in four regions were vaccinated – 80% were previously unvaccinated or undervaccinated.
Introducing HPV vaccine in Kosovo
Vaccination against human papillomavirus (HPV) can prevent cervical and other cancers. However, the vaccine has been subject to misinformation and rumours, making it challenging to maintain high coverage rates. Before introducing the vaccine in Kosovo, WHO experts collaborated with universities and national immunisation experts to jointly conduct insights research. ‘It is very important that we have skilled consultants working with local researchers, listening to all interviews, and developing a protocol together,’ Nielsen explained. ‘From the start, there is a sense of ownership about the project among the target community.’
The real value of listening to communities is evident when the research findings challenge prior assumptions. The rumours and reasoning that caused hesitancy in one region may not be significant factors in another.
For example, teenagers in Kosovo – and some health workers – had limited awareness of cervical cancer and, as a result, did not appreciate the opportunity to prevent it. Concerns about fertility, which were not grounded in evidence, were also recorded and addressed.
Following an information and training campaign informed by behavioural research, 80% of the target group in Kosovo (unvaccinated girls aged 12) was vaccinated.
Immunization Agenda 2030
As European countries step up efforts to meet the targets set out in the Immunization Agenda 2030 strategy, the focus on addressing pockets of low vaccine uptake is likely to sharpen. Behavioural insights research will have a key role in revealing the unique drivers of vaccination rates in specific communities.
‘Despite high vaccination coverage at national level, inequities visible at subnational level continue to leave individuals and population groups susceptible to vaccine-preventable diseases,’ said Nielsen. ‘Achieving high uptake of any vaccine requires exploring, understanding, and addressing the drivers of and barriers to vaccination.’
Mariano Votta, Director of Cittadinanzattiva-Active Citizenship Network, said the growing acceptance of behavioural insights and the inclusion of stakeholder voices in designing vaccine programmes, is a welcome trend.
‘Behavioural science aimed at public health objectives represents a valuable ally for improving vaccination rates, because it enhances two elements that we have always considered essential: listening to local communities and their direct involvement, to make them an active part of the change,’ said Votta. ‘This is why we are committed to extending the so-called ‘nudging methodology’ to vaccination policy among our constituency of civic and patients’ organisations across Europe’.
