*2.2. Factors Influencing Vaccination Uptake*

National programmes and policymakers often attribute sub-optimal vaccination coverage to refusal to vaccinate based on concerns about vaccines, but this is only one of numerous possible contributing factors. The factors influencing vaccination coverage at local level are complex and can range from individual socio-economic conditions to issues

around healthcare systems and accessibility of services [8–11]. Formative research and behavioural analysis of a Charedi Orthodox Jewish community of the London borough Hackney showed that critical issues related to sub-optimal immunization uptake were linked to access to and convenience of immunization services, both for the service providers and the population, while the assumption before the study was that under-vaccination was linked to cultural or religious anti-vaccination sentiment [16]. Several countries have shown that children living in poorer households, children born to mothers with lower levels of education and those residing in rural areas are more likely to be left behind in immunization uptake [17]. Vaccination coverage has also been found to be lower in specific population groups like asylum seekers, refugees, migrants and deprived communities in comparison to the general population [17–19]. In addition, studies have also demonstrated the role ethnicity can play as a cultural factor in influencing completion of scheduled vaccination doses [20,21]. Indeed, certain ethnic communities such as Roma and Sinti have often been disproportionately affected by outbreaks of measles [22]. Careful consideration of factors such as area of residence, living conditions and characteristics including age, gender, economic status, ethnicity, religion, migration status, education or disability will help national and subnational immunization programme managers to develop appropriate immunization delivery strategies that yield more equitable uptake.

#### *2.3. Immunization Inequity and Regional Immunization Strategies*

EVAP suggested that countries in the Region ensure that every individual is eligible to receive all appropriate vaccines, irrespective of their geographic location, age, gender, educational level, socioeconomic status, ethnicity, nationality or religious or philosophical affiliation [7]. EIA2030 builds on the successes and lessons learned through implementation of EVAP, with a vision and strategy for achieving the full benefits of immunization in the Region for the next decade, seeking to attain stronger and more resilient immunization programmes by focusing on three key principles: ensuring equity in immunization, providing immunization across the life course and devising local solutions to local challenges [12]. By ensuring that national immunization strategies have an equity-based approach to reach unvaccinated and under-vaccinated populations, EIA2030 aims to address the inequities in immunization coverage between and within countries through the use of innovative programming, better understanding of the concept of immunization equity and local-level interventions to identify and address barriers.

#### *2.4. Identifying and Addressing Immunization Equity*

In addition to determining the administrative areas of sub-optimal coverage by evaluating the routinely reported annual immunization coverage data, it is critically important for subnational immunization stakeholders to identify which populations groups in these areas have lower vaccination uptake and understand why they are not vaccinated. These will allow the stakeholders at the local level to devise tailored strategies to improve the vaccination coverage and thereby also reduce inequity.

Inequities are reflective of population groups in communities being left behind. As a starting point, understanding immunization inequities will require good-quality, robust disaggregated immunization coverage data at every level of a health system together with systematic monitoring. Since 2016, tools [23–25] developed by WHO have supported countries to illustrate socio-economic, demographic and geographic variation in uptake, enable comparisons of data about immunization (and other health parameters) within and across countries and devise analytical approaches to determine the factors associated with immunization coverage. Every country, through its network of national and subnational immunization programmes, should examine its local-level immunization uptake data to identify the presence or absence of inequities. Once population groups with low immunization coverage are identified, understanding the contextual issues they face is the next step toward improving vaccine equity and averting future outbreaks, especially among those who are also often at higher risk of severe but preventable outcomes. During EVAP

implementation, the WHO Regional Office for Europe supported countries in the Region through implementation of the "Tailoring immunization Programmes" (TIP) initiative to diagnose vaccination barriers and motivators in populations with low vaccination coverage and design tailored interventions to address these barriers [26]. Whilst TIP provided a framework for countries to understand the perspective of populations with low vaccination coverage, an external review of TIP implementation in four countries in the Region in 2016 suggested that the efforts should go beyond identification of susceptible groups and diagnosis of challenges [27].

The organization and delivery of vaccination programmes vary widely in the Region, [28] thus preventing or reducing inequities in immunization coverage will inevitably require local-level tailoring of resources or service provision for underserved individuals or populations to overcome or remove barriers to vaccination. Immunization programme monitoring must now go beyond national or regional estimates of immunization coverage and additional efforts should be made to understand how vaccination uptake varies according to socioeconomic, demographic and geographic factors within a country. It is time that simple and pragmatic guidance and tools are developed for the immunization stakeholders at all levels especially for those at the local health facility levels, to identify and understand barriers to immunization uptake. This will pave the way for the subnational immunization managers to develop and implement successful interventions addressing these immunization inequities coupled with periodic evaluation of the targeted interventions and mid-course corrections, if need be.
