Presentation by Anders Tegnell on implementation in Sweden of the WHO Guide to Tailoring Immunization Programmes (TIP), at WHO/Europe Immunization Programme Managers Meeting, Antalya, Turkey, March 2014

2. A WHO Europe collaborative project:
”Hard-To-Serve” populations with low
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vaccine coverage in Sweden
- how to better understand their decisons?
-how to find suitable interventions?

3. Tailoring immunization
Programs (TIP) –
to the needs of susceptible populations
1. Identify at-risk and vulnerable populations susceptible
to VPD or to characterize and stratify already
identifies target population at-risk
2. Determine barriers and motivators to vaccination
3. Design evidence based interventions based on the
results.
http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/vaccines-and-immunization/
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news/news/2012/06/tailoring-immunization-to-the-needs-of-susceptible-populations

4. Sid .

5. SWEDEN
MPR vaccination coverage >95%
Figure 1. Vaccination coverage at age 2 yrs for 3 doses
DTP-Polio-Hib-vaccine and 1 dose MMR-vaccine
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6. Vaccination coverage - 2012
Children at the age of 2 years (born 2010)
CHC (BVC)
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No. reg
children MPR DIFTERI TETANUS PERTUSS POLIO HIB PNEUM.
Järna
Järna 126 93,7 94,4 94,4 94,4 94,4 93,7 92,1
Kirstens familjeh 41 4,9 26,8 26,8 26,8 26,8 14,6 4,9
Rinkeby-Tensta
Rinkeby 323 71,5 87,9 87,9 87,9 87,9 87,9 76,2
Tensta FC 343 69,7 92,7 92,7 92,7 92,7 92,7 92,1
Göteborg Northeast and Angered
Angereds Läk 5 3 90,6 98,1 98,1 98,1 98,1 98,1 96,2
Bergsjön 267 94,8 97,0 97,0 97,0 97,0 95,5 94,0
Kortedala Torg 60 100 98,3 98,3 95,0 98,3 98,3 93,3
Kortedala 58 94,8 96,6 96,6 96,6 96,6 96,6 91,4
Familjehälsan 18 100 100 100 100 100 100 100
Angered 350 96,3 97,7 97,7 97,7 98,0 98,0 97,7
Lärjedalen 256 97,3 98,4 98,4 98,4 98,4 98,4 97,7
Gamlestads 262 98,5 96,2 96,2 96,2 96,2 96,2 95,4
Overall Sweden 2012
113739 97,2 98,4 98,4 98,4 98,3 98,2 97,5

7. Pockets of low vaccine coverage
Anthroposophic communities
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• Very low MPR coverage at age 2 years (4,9-40,3% in
2012).
• Recent outbreaks of measles (16 cases in 2012) and
rubella (50 cases in 2012).
• Population about 7000 , 167 born in 2009

8. Pockets of low vaccine coverage
Somali community northern Stockholm Rinkeby/Tensta
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• Low MPR vaccine coverage at age 2 years, presumably
still out of fear of autism (69-70,3% in 2012).
• Population 60000, 89% of foreign origin, 29% from
African countries, 875 born in 2010 in Rinkeby-Kista och
560 In Tensta-Spånga

9. Aim and objectives
• Aim: increase the understanding of how parents’
perceives health and disease and its role in their
decision regarding MMR vaccination for their children.
• The specific objectives are:
–To explore parents’ attitudes and perception towards
health, disease and vaccinations.
–To understand parents’ reasoning
–Facilitators and barriers to vaccination
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10. Methods – qualitative data collection
ANTHROPOSOPHIC SOMALI
• 19 in-depth
interviews with 20
parents
• Key-person
interviews
• Content analysis
• Litterature search
• Vaccination
coverage data
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• 12 in-depth
interviews with 12
mothers
• 11 health care
worker interviews
• Content analysis
• Litterature search
• Vaccination
coverage data

11. Anthroposophic interview results:
groups and subgroups
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Anthroposophic
community
Parents vacc
on time
Community
minded
Conformers
Parents vacc
<5yrs
Community
minded
Attentive
delayers
Pragmatists
Parents vacc
>5yrs
Promoters
of natural
immunity

12. Conformers
• Vaccinate at 18 months
• No strong anthroposophical beliefs
• “Vaccinating is something that you just do when having children. And I do not
see why you shouldn’t since you protect the children from having fairly severe
diseases”
• “I trusted the experts who implemented the program and so I trusted the
vaccines… Since the [MMR]vaccine has been used for a long time and there
are no known adverse effects that I know of, thus I believe it is a safe
vaccine.“
• “Community-minded”
– “I believe it is automatic that you consider the greater perspective for
vaccinations so that no one is affected. I think it is in the back of the mind”.
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13. Attentive delayers
•Community minded
•Vaccinate from 18 months to 3-4 years of age
•Consider themselves as being thoughtful not to expose
anyone else
• “We try to wait with vaccinations as long as possible because I believe that it
may interrupt the development.”
• “It was some worrying due to the responsibility. I did not want to risk that my
child is a carrier of the disease and transmits the disease to other
unvaccinated people during the incubation period before any signs of infection
may be noticed.”
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14. Pragmatists
•Community minded
•Vaccinate from 18 months to 3-4 years of age
• “And then measles shows up and you do not have the time to deal with it. In
the end, if you would get measles and you should have the ability to take care
of it then you need 5-6 weeks since it is a long
• “It is not certain that you have the energy to deal with it [measles] and if you
don’t then there is great that there is an option. It is really a complex
question.”
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15. Promoters of natural immunity
• Postpone vaccinations until 10-13 years of age
• “I learned early in life that disease is a part of life in some way and that one
cannot be healthy all the time and that one gets sick and then well again.”
• “It is some part of the anthroposophic reasoning that it [measles] is positive
and something that strengthens both physically and develops the personality.
It is both those things. That is what is strengthening”
• “We believe that fever is not a disease. It is a symptom of the body’s natural
process to fight diseases…You have to know how to deal with a child who has
fever.
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16. Promoters of natural immunity cont.
• “It is also about injecting substances in babies”
• The available information on the experience that was given during the two
epidemics in the community strengthened my perception that it is not that
severe. To my knowledge, no one had any complications. Nobody died so. It
feels like a risk that I can take for my daughter.
• “It is the parents who have to make the decision and make an informed
decision so that they feel that they can live with the consequences. Both
positive and negative”
•Prioritizing natural immunity
– Freedom to choose themselves
– Prioritize individual over herd immunity
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17. Results: Somalian parents in Rinkeby/Tensta
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Rejection
of other
vaccines
Persistence of perceived MMR vaccine
environ-mental
health
care
communi
ty
individual
Residing long in this
area
Negative attitude of
nurses
Peer pressure,
Grandmother, Husband
Postpone
vaccinating
New comer to this
area
Trust in nurses
Friend who vaccinated
their children
Vaccinating on time.
Trust in God.
side effect:
Child not speaking/ Autism
Reasons for
not
vaccinating
Reasons for
vaccinating

18. Conformers
• Newcomers more positive than integrated population
• ”..jag träffade en somalisk familj som flyttade från Linköping hit och det var
inga konstigt att ta MPR, det var bara ja ja. Det är här i Rinkeby det har blivit
ett jättestarkt rykte. Det är jätte spännande hur det kan rotas” (HCP10)
• Trust in health care personnel .. And trust in God
• ” nu frågar jag om råd hos BVC sköterskan. Förut var det somaliskt snack
som jag lyssnade..Hädanefter tar jag det BVC sköterskorna säger” (Parent 1)
• Friends who vaccinated their children
• ” är min enda vän som kom till här landet innan jag och kan språket, jobbar,
kan hälsofrågor. Hon har en son och hon vaccinerar sin son”
• Resisting Peer pressure
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19. Delayers
• Residing long in this area
• Negative attitude of nurses
• ”själva personalen är lite stressigt, för att de är har lite personalbrist och det
har de haft hela tiden” (parent 11)
• ”när jag gick dit sa hon alla somalier undviker den här sprutan och varför vill ni
inte vaccinera. Hon har alltså sina egna svar. Hon ville inte veta min förklaring”
• Peer pressure – MMR and risk of autism…Postponing
• ”snacket bland folk mitt barn har fått den här vaccinationen och innan var det
bra och nu när han har fått vaccination så blev det annorlunda. Så man är
rädd som förälder”
• Jag skulle behöva mer information för dt här 18 mån vaccinet det är den folk
säger barnen slutar prata. Därför väntar jag..se om han börjar prata ”
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20. Interventioner: Antroposoferna
Capacity building in health personnel to answer vaccine questions in
a respectful dialogue
Culturally acceptable and tailored communication
Increased acces to balanced MPR information
Use of social media to support communication
”Vaccine champion ” project
Stress the importance of vaccination before travelling
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21. Interventioner: Somaliska befolkning
Capacity building in health personnel to answer vaccine questions in a
respectful dialogue
Culturally acceptable and tailored communication
Increased access to balanced MPR information
Use of social media to support communication
”Vaccine champion ” project - peer-to peer education
Stress the importance of vaccination before travelling
Increased quality of Health Screening, incl vaccination status
Web based education on how to evaluate and plan complementary vaccination
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22. Hard to Reach project in Sweden
SUMMARY
• Workshop 2 days in March and August
• Qualitative studies/Content analysis – indepth interviews
– Anthroposophic population in Järna
– Somali population in Rinkeby/Tensta
– Migrants especially undocumented
• Applying for externa funds for implementation
• National web seminar with all health screening personal scheduled
• Hard- To- Reach direct input in
– National Elimination Action Plan
– National Vaccine Communication strategy
• TAP in development
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