Exploring Childhood Immunization among Undocumented Migrants in Sweden - Following Qualitative Study and the World Health Organizations Guide to Tailoring Immunization Programmes (TIP)

"The TIP guide offers a valuable process for a deeper understanding of the determinants of immunization challenges among undocumented migrants."

The South-North migration flow to Europe has raised questions about possible suboptimal vaccination coverage among the migrant population. Current knowledge about the immunisation status of undocumented migrant children is scarce. The aim of this study was to explore the views, attitudes, and experiences of undocumented migrants (parents) regarding childhood immunisation, using a qualitative approach called Tailoring Immunization Programmes (TIP), which was developed by the World Health Organization (WHO) Regional Office for Europe in 2013 and has been used in various settings in 12 countries as of 2019.

As detailed at Related Summaries, below, TIP is a participatory, people-centred process for diagnosing barriers and motivators for vaccination in communities with low vaccination coverage. TIP promotes the use of multiple information sources, performing qualitative research studies, review of the literature as well as incorporating additional information from experts and stakeholders through engaging workshops. The study was designed according to the formative research phase of TIP, consisting of 3 steps: (i) an initial workshop to define the situation and problem statement; (ii) individual in-depth interviews conducted from May-August 2013 with 7 undocumented parents with preschool children and 3 child health nurses from Child Health Centers (CHCs) to increase understanding of the vaccination practices of children in the undocumented community; and (iii) a second workshop to develop a conceptual framework. (Throughout this process, it is noted: "Research on undocumented migrants is a very sensitive issue, and therefore the research team regularly raised ethical issues and implications of the study objectives, data collection, and reporting.")

Findings from the qualitative interviews are presented. Themes included:

• Parental fear of being detected: Parents expressed a strong sense of fear of disclosure when seeking health care for either their children or themselves. The interviewed parents exhibited a high degree of trust in the nurses at the CHC but to a lesser degree in healthcare providers at primary health facilities. The families move frequently because of their illegal status, which complicates the follow-up of children's health and immunisation status.
• Vaccine acceptance: Nurses reinforced that awareness and knowledge of the importance of immunisations was high among undocumented migrants. Thus, vaccine hesitancy or refusal of immunisations among the undocumented parents in this study was not an issue.

The conceptual mapping was based on both the qualitative findings and additional information from the key stakeholders and experts, which together was used to visualise parental enablers and barriers to immunisations (see Figure 1 in the paper, and above). Overall, parents' attitudes to vaccinations or the intention to vaccinate are facilitating factors, whereas the uncertain social situation results in low prioritisation of vaccination. Consequently, the parents seem to be facing a structural problem rather than barriers at the individual level regarding acceptance of vaccinations.

In conclusion: "The systematic approach of the TIP method and its structured way of presenting qualitative findings facilitated the understanding of the barriers and enabling factors from various perspectives. Moreover, the TIP method helped to create a more complete and contextual situational analysis that went beyond mere individual characteristics and profiling and to also consider legal issues as well as structural, administrative, and financial obstacles outside the influence of the healthcare providers."