Addressing inequities in immunization: TIP implementation in Sweden

Sweden sustained high immunization coverage, with a rate of just over 97% for 3 doses of diphtheria-tetanus and pertussis vaccine (DTP3) and almost 97% for first dose of measles-mumps- and rubella vaccine (MMR1) in 2016. Despite this high national coverage, individual cases and outbreaks of vaccine-preventable diseases persist. Recurrent cases of measles demonstrate that vaccination programmes are not reaching everyone. Whilst the margin for inequalities in immunization is considered small, Sweden actively identifies communities where under- or un-immunization persists in efforts to achieve full and equitable immunization uptake across the whole population.

Background

Sweden’s high overall vaccination coverage is largely based on integrating immunization into preventive services at Child Health Clinics (CHC) scatted across the country. Vaccinations are administered and recorded by nurses at CHC who have a close relationship with the families living in their remit.  Sweden’s CHC have had sustained attendance rates of over 95% for over a century and are one of the reasons for its success in securing exemplary immunization uptake year after year.

Identifying inequities and implementing actions

In 2013, Sweden was one of the first countries to apply the Tailoring Immunization Programmes (TIP) approach developed by WHO/Europe. The TIP framework identifies which factors are important for parental decision-making about vaccination in groups with low vaccination coverage. In areas with low immunization uptake, the local Public Health Agency identified three population groups with low vaccination coverage:

• the anthroposophic community in Järna located south of Stockholm
• the Somali community in Rinkeby and Tensta in northern Stockholm
• undocumented migrants in Gothenburg and Stockholm.

The aim of  the TIP analysis in Sweden was to:

• better understand needs of vulnerable populations;
• identify parents’ barriers and motivating factors for bringing their children for the MMR vaccination;
• identify providers’ challenges to address inequities in uptake;
• identify targeted interventions to increase the uptake of MMR1.

As a first step, key informants, stakeholders and researchers met to conduct a situation analysis and define the research statement. 3 qualitative substudies were subsequently conducted based on in-depth interviews with parents and children, health clinic staff, health professionals and other informants. The results of these were structured according to the TIP model, and preliminary conceptual maps were produced for each substudy.

Based on combined quantitative and qualitative study results, research teams analysed the individual patterns of behaviour and important barriers and motivators to vaccination, and identified structural barriers to access within the health care system.

During a two-day workshop, the project team discussed the results of the formative research phase and identified strategic priorities for designing feasible and relevant interventions. The interdisciplinary project group represented broad knowledge on vaccines, epidemiology, health communication, research methods and local service provision. Several follow-up meetings were also held with smaller project groups, and through them interventions were planned in detail. A national communication strategy for reaching the marginalized and underserved in Sweden was also developed.

Changing practice

The results of the TIP analysis showed that parents in the three communities wanted more information and education about vaccines and the diseases they prevent. In response to these findings the Swedish Public Health Agency developed evidence-based and culturally sensitive interventions such as:

• an information card with brief information about vaccinations in both Swedish and Somali languages.
• a film about childhood vaccinations available in Swedish and Somali languages, featuring parents and highly regarded community members discussing why they have chosen to vaccinate their children and why they think vaccination is a wise choice; (the film is also available online);
• a peer to peer group, involving community members to act as ambassadors to improve relationships between health care providers and families -  interested and committed parents were trained in children's health, vaccinations and childhood diseases and actively shared the information with others in their own social networks;
• additional training and support for vaccine providers to meet the needs of different communities and address vaccine hesitancy in all areas of the population.

Learning points

The Swedish context and TIP project provided useful insight for other immunization programmes, including evidence that integrating vaccination services into existing health care structures is highly effective, and that close long-term relationship between health care providers and families fosters trust  and confidence in vaccine services.