A review of evidence on equitable delivery, access and utilization of immunization services for migrants and refugees in the WHO European Region

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Vaccines and Global Health: The Week in Review has expanded its coverage of new reports, books, research and analysis published independent of the journal channel covered in Journal Watch below. Our interests span immunization and vaccines, as well as global public health, health governance, and associated themes. If you would like to suggest content to be included in this service, please contact David Curry at: david.r.curry@centerforvaccineethicsandpolicy.org
 
 
A review of evidence on equitable delivery, access and utilization of immunization services for migrants and refugees in the WHO European Region
WHO Health Evidence Network Synthesis Reports 53.  – 55 pages
Editors – De Vito E, Parente P, de Waure C, Poscia A, Ricciardi W.
Source – Copenhagen: WHO Regional Office for Europe; 2017.
PDF: https://www.ncbi.nlm.nih.gov/books/n/whohen53/pdf/
Excerpt
This review focuses on existing immunization policies and practices for migrants and refugees and provides an overview of barriers and facilitators for access to and utilization of immunization services. Evidence was obtained by a scoping review of academic and grey literature in English and a further 11 languages and included official documents available from the websites of ministries of health and national health institutes of the WHO European Region Member States. The review highlights that vaccination policies tailored to migrants and refugees are very heterogeneous among WHO European Region Member States. By comparison, common barriers for the implementation and utilization of immunization services can be identified across countries. Outlined policy options are intended to strengthen information about immunization for migrants and refugees, support future evidence-informed policy-making, enable the achievement of national vaccination coverage goals and improve the eligibility of migrants and refugees to access culturally competent immunization services.
 
SUMMARY
The issue
Providing equitable access to safe and cost-effective vaccines is vital to protect vulnerable groups in any country and to reduce morbidity and mortality from vaccine-preventable diseases (VPDs), particularly among children. Migrants and refugees in the WHO European Region may be particularly vulnerable to VPDs. Children, who constitute approximately 25% of the total migrant population, are considered at greatest risk of VPDs because they may not have yet been vaccinated or may not have completed the schedule for all vaccines. In November 2015, WHO, the United Nations High Commissioner for Refugees and the United Nations Childrens Fund made a joint recommendation that migrants and refugees in the WHO European Region should be vaccinated without unnecessary delay according to the immunization schedule of the host countries. The WHO European Region’s Strategy action plan and resolution on refugee and migrant health, adopted in September 2016, addresses the issue of immunization among migrants and refugees.

The synthesis question
The objective of the review is to address the following question: “What is the evidence on equitable delivery, access and utilization of immunization services for migrants and refugees within WHO European Region?” The review focuses on existing immunization policies and practices for migrants and refugees and provides an overview of barriers and facilitators for access to and utilization of immunization services.

Types of evidence
Evidence was obtained by a scoping review of academic and grey literature, in English and Russian, including official documents available from the websites of ministries of health and national health institutes in the Region. A total of 56 articles/papers/documents published between 2007 and July 2017 were considered for this review.

Results
Immunization policies, vaccine delivery practices and barriers to access and utilization of immunization services by migrants and refugees vary widely in WHO European Region:
:: national immunization programmes seldom include specific recommendations for immunization for migrants and refugees;
:: fewer than one third of the countries have specific directives on immunization focusing on migrants and refugees, including children and pregnant women;
:: undocumented migrants receive immunization services in very few countries because of inbuilt administrative barriers in the host countries related to their entitlement to free health services, including immunization;
:: in most of the countries of the Region, the delivery of immunization services is primarily carried out by the public health care systems, but international organizations and nongovernmental organizations are also involved in a few;
:: lack of financial and human resources, in particular cultural mediators and/or interpreters, is seen as a barrier to the effective implementation of national immunization policies and to the systematic collection and evaluation of data for corrective actions;
:: socioeconomic, sociocultural and educational issues remain important obstacles for migrants and refugees in accessing the available immunization services in the host countries; and
:: targeted interventions have been shown to be successful in improving the uptake of immunization programmes among migrants and refugees, for example door-to-door vaccination initiatives, media campaigns, thematic lectures, peer-to-peer interactions and health promotion days.

Policy considerations
A systemic and tailored approach to the management of immunization among migrants and refugees is critical. Adequate protection of migrants and refugees from VPDs may require long-term strategies by national health systems. This review suggests the following policy options to be considered by policy-makers in strengthening immunization for migrants and refugees in the WHO European Region.

:: Ensure national policies are in place for provision of equitable and high-quality
immunization services tailored to migrant and refugee populations:
– national immunization programmes should ensure that migrants and refugees benefit from easy access to the vaccines offered free of charge under the national vaccination schedule; and
– appropriate strategies, such as outreach activities, and existing initiatives, such as tailored immunization programmes, should be considered to improve the delivery and uptake of vaccines.

:: Provide appropriate administrative mechanisms and ensure political commitment to address the existing barriers to vaccination service delivery and utilization; useful interventions include:
– interpreters and cultural mediators to support interactions;
– provision of information in the languages of the migrants;
– models for collection of relevant data on migrants and refugees that avoid issues of stigma and discrimination;
– effective collaboration on service delivery between national health services, existing social services networks and local service providers in the country;
– provision of adequate training and culturally relevant information for health care professionals to ensure that they understand the specific needs of the migrants and refugees they link with and can avoid detrimental inappropriate behaviours and/or stereotypical attitudes; and
– inclusive decision-making that involves migrants and refugees during planning and implementation of vaccination programmes.

:: Promote strategies to address wider issues such as marginalization, health literacy and other social determinants of health that contribute to low vaccination coverage among migrants and refugees.

:: Develop realistic implementation plans together with a robust monitoring and evaluation framework to review existing policies periodically in light of population movement and VPD epidemiology in the host countries.

:: Foster research to further understand and address the barriers related to immunization service delivery and utilization in these groups.

:: Devise appropriate mechanisms to promote cross-border collaboration and sharing of good practices among countries in the Region.