Design and Implementation of Tailored Intervention to Increase Vaccine Acceptance in a Somali Community in Stockholm, Sweden - Based on the Tailoring Immunization Programmes Approach

"The TIP approach was helpful in guiding the working process with a stepwise systematic process to achieve a thorough understanding of barriers and drivers for MMR vaccination among parents in the targeted Somali community."

Addressing vaccine hesitancy is a global priority, and public health authorities are searching for effective strategies to build vaccine confidence. Developed by the World Health Organization (WHO) Regional Office for Europe, Tailoring Immunization Programmes (TIP) offers a process through which to identify populations with lower immunisation coverage, to understand their barriers and drivers to vaccination, and to develop tailored and targeted interventions accordingly. This article describes the formative research (phases 1 & 2), as well the intervention design and implementation (phase 3 & post-TIP), of a TIP project conducted to address low measles-mumps-rubella (MMR) vaccine acceptance among parents in a Somali community in Stockholm, Sweden.

The TIP approach has been implemented in at least 12 countries, reaching various communities, and several papers have been published describing the TIP process. (See, for example, Related Summaries, below.) The theoretical underpinning of TIP is the Capability, Opportunity, and Motivation (COM-B) model and Behaviour Change Wheel (BCW) framework, adapted for vaccination. In the Stockholm project, which the Public Health Agency of Sweden (PHAS) launched in 2013, the COM-model was used to identify barriers and drivers to vaccination and intervention types.

The community where the project was carried out is located in Rinkeby and Tensta, two neighbouring districts in northern Stockholm, where approximately 30% of the residents are of Somali origin. The area has an increased risk of outbreaks due to low MMR vaccination rates (around 70%) since 2002, a date that coincides with the publication of a later-refuted article by Andrew Wakefield on a presumed link between autism and the MMR vaccine.

The paper describes each phase of the TIP process in this context, beginning with pre-TIP (planning). One aspect of this planning involved a community reference board (CRB) consisting of five Somali-speaking community organisers and social workers that provided guidance and expertise for intervention design and implementation. Phase 1 - situation analysis - aimed to get an overview of existing evidence regarding barriers and drivers to MMR vaccination in the Somali community with the support of stakeholders. Phase 2 - research - built on the insight from the situational analysis through two linked qualitative studies that sought to understand the perspective of Somali parents and child health nurses on these issues.

In short, the research revealed that parents who did not vaccinate their children according to the schedule for the first dose MMR at 18 months feared that the vaccine would cause side effects such as autism or that their child would stop talking following MMR vaccination. Newcomers to the area have in general a more positive attitude towards vaccines; however, they become more skeptical and vaccine hesitant the longer they live in the area due to peer pressure not to vaccinate their children. These concerns are reinforced by a perception of unpleasant encounters with nurses. The results highlighted a need for support in skills and training to improve communication and dialogue with hesitant parent for nurses. In addition, findings indicated that the communication format strongly preferred by parents was oral communication in Somali language, since the word-of-mouth tradition is strong in the Somali community, and information and knowledge is passed through personal relationships.

In order to design the intervention, which was implemented from 2015 until end of 2017, barriers were linked to their associated COM-B factors and mapped to appropriate intervention types for two groups: Somali parents and nurses at the Child Health Centres (CHCs). Key barriers were selected as: parents' need for increased knowledge (capability), fears (motivation), and negative social pressure (social opportunity); as well as CHC nurses' need for training, skills, and confidence for difficult vaccination conversations (capability). Selected intervention types targeting parents were education, persuasion, and modelling, whereas education and training were selected for CHC nurses. Discussion about ideas for activities focused on acceptability to the two groups, as well as the feasibility of delivery in terms of budget and timeline.

In the beginning of phase 3, intervention activities were piloted and tailored to the needs of the two groups (parents and CHC nurses). The community members participated in all phases of the intervention at different levels. For instance, they helped organise seminars and convey knowledge to the community by dissemination of information through existing networks and platforms in the community. Specifically, the intervention activities included:

1. For Somali parents:
   • Four dialogue-based public seminars were held, free of charge, during the weekends in October-November 2015 at local and accessible venues in Rinkeby and Tensta. Delivered by vaccination experts, the first type focused on general child health, including information about how vaccines work, etc. The second type of seminar, which was delivered by two child psychiatrists, focused on child development, including factors that influence early child development and in-depth information about autism. One of the vaccine experts and one of the child psychiatrists were Somali speaking, which added a level of cultural authenticity to the knowledge sharing.
   • An information card for parents with five brief key messages on childhood vaccination was printed conveying key messages in Somali and Swedish in a postcard format with a QR-code and in PDF format for easy dissemination. It was distributed to and used by nurses at CHCs and other stakeholders - e.g., preschools.
   • A web page linked to the website for the national immunisation programme (NIP) at the PHAS was launched where relevant information for the TIP project Sweden was gathered and shared. The information card included the link to the website to facilitate easy access to all information about the project and the two films (below).
   • A 14-minute narrative film with Somali role models entitled "Vaccination - a wise choice for your child" was created and posted on the PHAS website. (It was also presented to parents at different venues such as preschools and social events, and nurses actively used it in their encounters with parents.) In the film, Somali-speaking parents shared their personal stories regarding their vaccination decisions, and vaccine experts shared evidence-based vaccination knowledge. The film also featured an active community leader with deep knowledge of Islam who shared his views on prevention and the importance of seeking relevant knowledge from a religious perspective to improve one's health.
   • A 7-minute animated cartoon, requested by the parents, was produced and posted (privately) on YouTube, with the overall aim to convey knowledge and facts about the immune system and vaccination, using visual illustrations and subtitles to reach a wider audience.
   • A peer-based intervention that focused on vaccination knowledge and communication skills in Somali and Swedish language was designed to empower peers to further inform other parents in their communities. In total, 32 mothers with different backgrounds and professions joined the peer group, all very active and engaged in the community in one way or another. After completion of the peer training, follow-up peer meetings were held once or twice each semester throughout the implementation phase. The follow-up activities aimed to sustain engagement and further advance the previous training and discuss related issues such as human papillomavirus (HPV) vaccination. WhatsApp was adopted as a strategy to keep the peer group connected and informed on relevant news - for example, local outbreaks of measles in Stockholm 2017 and another outbreak in Gothenburg 2018.
2. For CHC nurses, a series of tailored seminars were developed, as a group-level intervention, in collaboration with the Child Health Services to increase nurses' knowledge and competence for improving encounters and dialogue with vaccine-hesitant parents.

The TIP Core Group (TCG) presented the project at regional, national, and international seminars, workshops, and conferences. Other stakeholders and policymakers at the national, regional, and local level were reached for both disseminating purposes and also for raising awareness of the importance of addressing low vaccine acceptance at the local level. The aim was to inform key stakeholders in order to advocate support for long-term solutions and sustainability of the intervention.

Data are being collected until 2022 to evaluate the intervention, with a focus on both process and impact evaluation. The evaluation is based on a mixed-methods approach, involving both qualitative and quantitative methods of data collection and analysis.

The paper discusses good practices and lessons learned from the experience. For example, workshops held with an interdisciplinary team of experts and key informants during the planning phase were essential to get a comprehensive view and to facilitate discussions during both the situational analysis and research phases.

In conclusion, the insights gleaned through this TIP project in Sweden may be scaled up or replicated and tailored to other communities or groups with low vaccine acceptance where similar preventive intervention approaches are needed.