Improving childhood vaccination in minorities: a realist review of health system interventions

Abstract Background Most minority populations in Europe have lower childhood vaccine uptake than the general population. Improving uptake in these populations requires specifically developed, context-specific interventions. As part of the EU-funded RIVER-EU project, we conducted a realist review to identify interventions effective at improving vaccine uptake among underserved communities. Methods We searched MEDLINE, EMBASE, CINAHL, COCHRANE, and Proquest for articles published between 2005 and 2022, using combination keyword searches in English. Following title and abstract screening, full texts were assessed for relevance. We also searched grey literature and references of references. Data extraction and analysis was performed by two reviewers. Programme theories were generated from included articles and data extraction were carried out paying particular attention to context, mechanisms, and outcome configurations. Results From 1942 screened titles we selected 87 studies for full-text review of which 34 were included. We identified 10 primary intervention categories: parental and youth education; clinic outreach; quality improvement; health provider training; school-based education; technology interventions; cash incentives; home visits; comic books; community leaders education; and consent policy changes. The analysis highlighting contextual factors enabling or hindering each intervention category’s success is ongoing. Conclusions Several intervention categories can potentially improve vaccine coverage among underserved minority populations. We will describe their effectiveness and the contextual factors contributing to their success or failure to inform the development of tailored interventions targeting these populations. Key messages • Improving vaccination in underserved minority populations requires identification of effective interventions, barriers/enablers to their success, specific to the context in which they are implemented. • Appropriately tailored health system interventions are effective at improving vaccine uptake among underserved minority communities.


Background:
Cervical cancer caused by human papillomavirus (HPV) is the most frequent cancer in women in many low-income countries.Tanzania implemented a national HPV vaccination program in 2018 using a two-dose quadrivalent HPV vaccine. This study aimed to (1) estimate financial and economic costs of a two-dose vaccination program based on experiences with the national vaccination program, (2) estimate costs of a one-dose vaccination schedule to enable future cost-effectiveness analyses, and (3) assess the effect of alternative assumptions for future vaccination coverage rates on estimated costs of vaccination.

Methods:
The WHO Cervical Cancer Prevention and Control Costing (C4P) tool was used to estimate the incremental costs of the national vaccination programme from the perspective of the Tanzanian government using data collected via surveys, workshops, and interviews with local stakeholders. Deterministic sensitivity analyses were performed to estimate the effect of alternative assumptions for coverage rates and delivery strategies and to assess the impact of a potential onedose vaccination schedule.

Results:
The total financial and economic costs were US$10,117,455 and US$45,683,204,respectively,at

Conclusions:
The overall cost of Tanzania's HPV vaccination program was lower per vaccinee than previous demonstration projects in the region suggest. These data provide important baseline data for Tanzania's HPV vaccination program to date and may serve as a guide for improving coverage going forward. The findings may also aid in the prioritization of funding for countries that have not yet added HPV vaccines to their routine immunizations.

Key messages:
If a single dose regimen were found to be as effective as a twodose series, it would result in significant cost savings as well as an increase in the number of girls that could be reached. School-based vaccinations resulted in the lowest price per fully immunized girl, but other settings are needed to achieve equitable high coverage of HPV vaccination in Tanzania.

Background:
Studies have shown the low uptake of the human papillomavirus (HPV) vaccine among university students. Knowledge about the HPV virus and the vaccine can be a factor that may sway an individual's decision to receive the vaccine. This study aimed to investigate HPV vaccine uptake and knowledge about HPV vaccination among Croatian university students.

Methods:
This cross-sectional questionnaire study was conducted from February to May 2021 period. A validated, anonymous questionnaire that contained questions regarding demographic data, data about HPV vaccine uptake, and data regarding knowledge about the HPV virus and the vaccination was selfadministered to a cross-faculty representative student sample of the University of Osijek in Eastern Croatia.

Results:
The study sample included 840 subjects with, median age of 20 years (interquartile range 20-21), 45.8% males, and 54.2% females. The prevalence of vaccination uptake in the studied population was 20.8%. The study revealed that there were 25.6% of students with a low level of knowledge and 74.4% of students with satisfactory levels of knowledge about the HPV virus and the vaccination. The excellent knowledge about the HPV virus and the vaccination was more frequently shown by students who studied in biomedicine and health area of science (p < 0.001) and students with an excellent average grade of study (p < 0.001). HPV vaccination uptake was higher among females (p < 0.001), students who studied within biomedicine and health area of science (p < 0.001), students with an excellent average grade of study (p < 0.001), and students who showed excellent knowledge about the HPV virus and the vaccination (p < 0.001).

Conclusions:
The majority of Croatian university students had a satisfactory level of knowledge about the HPV virus and the vaccination but the vaccination uptake is still very modest. Additional efforts are needed to organize more appropriate education and promotion of vaccine uptake in the studied population.

Key messages:
The HPV vaccination uptake among Croatian university students is very modest although the majority of students have a satisfactory level of knowledge about the HPV virus and the vaccination. Continuous examination of HPV knowledge gaps and identification of factors influencing vaccine uptake is key to increasing vaccination rates in the Croatian university student population.

Background:
Most minority populations in Europe have lower childhood vaccine uptake than the general population. Improving uptake in these populations requires specifically developed, contextspecific interventions. As part of the EU-funded RIVER-EU project, we conducted a realist review to identify interventions effective at improving vaccine uptake among underserved communities.

Methods:
We searched MEDLINE, EMBASE, CINAHL, COCHRANE, and Proquest for articles published between 2005 and 2022, using combination keyword searches in English. Following title and abstract screening, full texts were assessed for relevance. We also searched grey literature and references of references. Data extraction and analysis was performed by two reviewers. Programme theories were generated from included articles and data extraction were carried out paying particular attention to context, mechanisms, and outcome configurations.

Results:
From 1942 screened titles we selected 87 studies for full-text review of which 34 were included. We identified 10 primary intervention categories: parental and youth education; clinic outreach; quality improvement; health provider training; school-based education; technology interventions; cash incentives; home visits; comic books; community leaders education; and consent policy changes. The analysis highlighting contextual factors enabling or hindering each intervention category's success is ongoing.

Conclusions:
Several intervention categories can potentially improve vaccine coverage among underserved minority populations. We will describe their effectiveness and the contextual factors contributing to their success or failure to inform the development of tailored interventions targeting these populations. Key messages: Improving vaccination in underserved minority populations requires identification of effective interventions, barriers/ enablers to their success, specific to the context in which they are implemented. Appropriately tailored health system interventions are effective at improving vaccine uptake among underserved minority communities.

Background:
The constantly growing refugee population may constitute public health threat in Poland in the context of COVID-19 pandemic. This study objective was to investigate COVID-19 knowledge among Ukrainian refugees in Poland.

Methods:
This cross-sectional study was carried out between March-April 2022 among Ukrainian refugees registering in Zielona Gó ra, Poland. An anonymous, self-administered questionnaire was used which included 10 questions related to COVID-19 knowledge. Each correct answer was given 1 point.

Results:
Response rate was 96.0%, 190 Ukrainians responded (mean age 37.8AE15.7 years; 42.1% males); 52.1% were living in the cities >50,000 inhabitants; 61.6% reported high SES; 39% higher education; 44.2% were married. The mean knowledge score was 3.47 (SD AE 2.2), 15.8% collected >50% points. The knowledge level was higher among those with higher SES (p < 0.0001) and higher education (p = 0.003); 31.7% stated that SARS-CoV-2 is an animal-human transmitted disease (more with high SES, p = 0.004), 55.0% considered COVID-19 as highly contagious disease (more living in bigger cities, p = 0.04), 26.3% reported that SARS-CoV-2 infection ensures lifetime immunity (more unmarried, p = 0.02); 24.7% correctly stated that compared with 18-to 30-year-olds COVID-19 mortality rate is about 10 times higher in those who are >65 years (more with higher education and high SES; p < 0.05, p = 0.01 respectively), 44.4% -that COVID-19 treatments are now available (more with high SES and higher education; p = 0.03 both). Regarding prevention, 37.0% reported that FFP3 is the most protective type of mask, 43.3% that vaccines effectively protect against COVID-19 (more with high SES; p = 0.006, p < 0.001 respectively). Conclusions: COVID-19 knowledge among Ukrainian refugees in Poland was far unsatisfactory, in particular among those with lower education and lower SES. Educational campaigns are urgently needed to effectively raise the knowledge level in this vulnerable group to better control the pandemic. Healthcare workers are a professional group subject to a risk of occupational exposure to a variety of infectious agents. From a public health perspective, their immune status has a great impact on the worker's own health, on the patients and on the general population. Measles, mumps, rubella, and chickenpox are vaccine-preventable diseases caused by viruses. Seroprevalence surveys are a powerful evaluation tool that provide information on the frequency, distribution, and dynamics of communicable diseases. In this study, the prevalence of immunity to measles, mumps, rubella, and varicella viruses was analyzed in healthcare workers in a General Hospital of Granada (Spain). A cross-sectional study examining the seroprevalence was carried out in a population of health professionals incorporated into the General Hospital between January 2021 and February 2022. 260 professionals were studied, classified into groups according to age: 20-29, 30-39. Serum determination of IgG to measles virus was performed using a marketed chemiluminescent immunoassay. The resulting seroconversion rates were: 66.54% measles, 89.75% rubella, 84.62% mumps, and 88.08% chickenpox. The lowest rates were observed for measles, resulting in a minimum among professionals between 20-29 years of age, with a seroconversion rate of 65.4%. In general, women had a higher percentage of antibodies against measles. The highest rates were for the varicella virus, reaching up to 93.18% among health professionals between 30-39 years old. Considerable decrease in titers of antibodies against measles is observed in healthcare workers, especially in the age group 20-29 years, which may be due to the loss of serological protection as time goes by since vaccination with the 2nd dose of Triple Viral,