Under-Vaccinated Groups in Europe and Their Beliefs, Attitudes and Reasons for Non-Vaccination; Two Systematic Reviews

"It is...important to carefully test vaccination messages in a specific group."

Despite effective national immunisation programmes in Europe, some groups remain incompletely or un-vaccinated, with underserved minorities and certain religious/ideological groups repeatedly being involved in outbreaks of vaccine preventable diseases (VPD). This study is part of one of the Work Packages (WP) of the European Union (EU)-funded project "Effective Communication in Outbreak Management: Development of an Evidence-based Tool for Europe". The aim of this paper's contribution to the project is to identify vantage points for communication strategies and present suggestions for communication with under-vaccinated groups (UVGs) that can be used effectively by health professionals and agencies throughout Europe, in case of an epidemic or pandemic of a VPD. To that purpose, this paper describes how to identify UVGs in Europe and explores the factors (beliefs, attitudes, and reasons) for poor uptake of vaccination in order to know with whom and how to communicate.

The researchers defined a UVG as a group of persons who share the same beliefs and/or live in socially close-knit communities in Europe and who have/had historically low vaccination coverage and/or experienced outbreaks of VPDs since 1950. For the first systematic review, they selected 48 articles out of 606 studies that described a group in Europe with an outbreak or low vaccination coverage for a VPD; for the second systematic review, they selected 13 articles from 406 studies that described possible factors that are associated with non-vaccination in these groups.

A look at these studies led to identification of 5 UVGs: Orthodox Protestants (11 articles), Anthroposophists (9 articles), Roma (18 articles), Irish Travellers (7 articles), and Orthodox Jewish communities (8 articles) (2 articles mentioned 2 UVGs and 1 article mentioned 4 UVGs, thus totalling 48). The paper briefly describes each of the 5 UVGs. The second literature search produced a list of factors regarding vaccination (beliefs, attitudes, and reasons) for each UVG, which is presented in Table 3 in the paper; the factors are briefly explained per UVG. For example, a Dutch study among Orthodox Protestant (OP) parents found that the main argument for those who refuse vaccination was the necessity to rely on Divine providence: If God sends an illness to somebody or an outbreak on earth, he has a reason to do so.

In short, the researchers found several common beliefs related to non-vaccination in these UVGs that could help to find policy vantage points for communication with these groups. Communication strategies regarding these similar factors such as educating people about the risks associated with being vaccinated versus not being vaccinated, addressing their concerns, and countering vaccination myths present among members of a specific UVG through a trusted source can establish a reliable relationship with these groups and increase their vaccination uptake. Furthermore, other interventions, such as improving access to health care, could increase vaccination uptake in Roma and Irish travellers, in particular.

Concluding thoughts: "to reach UVGs it is important to co-operate with these groups and to adapt the information to their specific needs....The epitheton 'hard-to-reach' should be abandoned, as not all groups are hard-to-reach and each group has its specific reasons and even individuals with in a group may differ for which specific approaches are needed and not general ones. Better that each country determines its own UVGs with their own beliefs and starts to develop trustful relationships."