Most parents vaccinate their children on time, every time. For the minority who don’t, it can be tempting to think that they have specific objections to vaccination or that they don’t trust doctors and health authorities.
But sometimes, there is another explanation.
Imagine having seven children and living in a big bustling city without a car. The volume of medical appointments and school runs, along with the challenges of managing kids’ homework and extracurricular activities, could become overwhelming.
If you successfully mobilise the family for a bus trip to the health centre because one of them is due their next jab, it would be very discouraging if you had to wait, sometimes for a long time to be seen – or if the waiting room had no books and toys, nor facilities for feeding and changing babies.
These are the kinds of practical challenges revealed by researchers studying the ultraorthodox Jewish Charedi community in northeast London where birth rates are high but vaccine uptake is lower than average.
Immunisation rates are too low to achieve herd immunity against highly-contagious diseases such as measles. Recurrent measles outbreaks have caused concern for the estimated 30,000-strong community and the wider population.
Three years ago, health officials decided to use the Tailoring Immunization Programmes (TIP) approach developed by the WHO Regional Office for Europe. It involves interviewing service users, health professionals and other community stakeholders to identify barriers and drivers to vaccination, before devising a strategy designed to increase uptake.
Between 2014 and 2016, Public Health England and NHS England worked with the community (including rabbis), and health providers to draft a set of recommendations. The program was reviewed by WHO officials in September 2016 and it is included in a report published in 2017.
By listening to parents – primarily mothers in this case –four broad categories of decision-maker with distinct motivations were identified: the concerned mother; the culturally and religiously adherent mother; the busy mother; the mother who is sceptical of health authorities.
While some had previously assumed that there was general distrust of health authorities or religiously-grounded vaccine hesitancy, other issues emerged from surveys and workshops with parents, health workers, community NGOs and a local rabbi.
‘The majority vaccinated and wanted to protect their children but convenience of accessing services was a major issue for those with large families,’ says Katrine Bach Habersaat, Technical Officer, Vaccine-preventable Diseases and Immunization, WHO Regional Office for Europe. ‘Bringing small children to a health facility and having nowhere to put the buggy when you get there were raised as practical concerns.’
Flexibility is important, drop-in clinics were seen by some as a more convenient option than fixed appointment times. Being able to attend immunisation clinics in local community venues such as children’s centres was also valued by mothers. By making relatively simple changes to the appointments system to accommodate parents, it is hoped that vaccine uptake will increase.
Another issue identified through the project was the need to make immunisation a positive community norm. While there was no specific religious objection to vaccination, there had been no explicit endorsement either.
‘In a community with strong community norms, for example on what to eat, how to dress and where to live, there is a lot to live up to,’ says Bach Habersaat. ‘Efforts are now being made to strengthen immunisation as a social norm.’
The impact of these specific changes will become evident in the coming years but the TIP approach can be applied to many subgroups where vaccination rates are low.
Ultraorthodox Jewish communities, Somali migrants, anthroposophic communities and undocumented communities may not have much in common – except that TIP has been piloted in all four groups.
A WHO Europe report on how TIP has been applied shows its versatility. Drawing on social marketing and several other strands of behavioural science, it is especially valuable in population groups with complex challenges.
In Sweden, very high average vaccine uptake rates mask serious problems with a number of subgroups. This explains why, despite strong vaccine acceptance, there are pockets of susceptibility where measles outbreaks continue to occur.
MMR uptake in the anthroposophic community has been estimated to be as low as 5% while DTP and polio vaccination is slightly higher at 28% in an anthroposophic child health clinic.
In Sweden’s Somali immigrant community, MMR uptake is around 70% – a hangover from the late 1990s scare that falsely linked the vaccine with autism. Following a TIP analysis, tailored interventions have included dialogue seminars, films with Somali role models and direct contact. People from the Somali community were also trained to offer peer-to-peer support on this sensitive topic, using existing channels and social networks. Nurses were trained and supported in culturally adapted communication to discuss child development with parents as well as MMR-vaccine related issues.
Interviews with members of the anthroposophic community revealed considerable variation in worldview: for some, opting out of vaccination was strongly linked to their sense of identity, while others were happy to send their children to anthroposophic schools but were less attached to the philosophy.
‘This group can be segmented into a number of subgroups ranging from those who vaccinate over the more pragmatic and the attentive delayers to the non-vaccinators who see diseases as a natural part of life,’ explains Bach Habersaat. ‘Different strategies are needed for each of these groups.’
Bach Habersaat says that unlike traditional education and communication strategies, TIP focuses on understanding the specific needs of population subgroups. ‘Sometimes there are misunderstandings about vaccination and more information is needed so that informed choices can be made,’ she says. ‘Often there are structural issues that can be addressed to improve convenience or the cultural appropriateness of services.’