Measles Outbreak in Romania: Understanding Factors Related to Suboptimal Vaccination Uptake

"No one action can turn this situation around; a multipronged strategy is needed tailored to the needs of different population groups."

An ongoing measles outbreak in Romania, 2016-18, indicates sub-optimal vaccination. This study was conducted to: (i) clarify who was affected by the outbreak, (ii) identify their barriers and drivers to vaccination, and (iii) explore whether these factors varied by population group. The goal is to inform actions to avoid future outbreaks, tailored to the needs of different population groups.

Outbreak surveillance data for 6,743 measles cases were reviewed to identify key characteristics. In addition, a survey was administered via telephone to 704 caregivers of measles cases (520 respondents). The questionnaire was designed using the World Health Organization (WHO) Tailoring Immunization Programmes (TIP) approach and building on the COM-B model, which identifies necessary conditions for behaviour change: capability (individual ability to enact the behaviour), physical and social opportunity (external physical or social environments that enable or inhibit the behaviour), and motivation (individual mechanisms that enact or inhibit behaviour).

Most measles cases had received no (97%) or one dose (2%) of the measles, mumps, and rubella (MMR) vaccine and lived in communities with suboptimal MMR vaccination coverage in 2015. There was a considerable over-representation of low education and ethnic minorities and of rural population among measles cases.

Table 2 in the paper presents a summary of responses to physical/social opportunity, capability, and motivation statements. For example, 79.4% said they were satisfied with the information they receive from the family doctor about vaccination, 75.2% said the media (TV, radio, newspapers) generally support vaccination, and 80% agreed that "most people who are important to me think that children should get vaccinated". The majority thought that measles is a potentially serious disease that can cause harm (92%), that vaccination is important for their child to have a healthy life (88%), and that vaccination is important to prevent spread of disease in their community (89%). Some concerning findings:

• Only 24% said their family doctor had provided clear information about potential side effects.
• Only 58% reported they had received information from the doctor's clinic about their child's next vaccination; minority population respondents were 1.5 times more likely than majority population respondents to report they had not been informed.
• Only 71% knew where to go for information about vaccination. Minority population respondents were 1.5 times as likely as majority population not to know where to go for information. Those with no education/primary education were 3 times as likely not to know where to go compared with those with tertiary education.
• Only 46% knew when it was time for their child's next vaccination.
• 17% did not know/did not respond or disagreed (11%) with the statement that vaccines are generally safe for their child.
• 28% did not know/did not respond or disagreed (9%) with the statement that the potential risk of vaccine side effects is small.

In short, the study found that barriers to vaccination in Romania are complex and relate to all factors of the COM-B model. Disadvantaged groups, such as minority, mobile, and low-education groups, were highly over-represented among measles cases, and capability and physical opportunity barriers to vaccination were particularly evident for these groups. Studies elsewhere confirm an association between low immunisation uptake and social determinants that are associated with other health inequities. For those with higher education levels, the challenges related more to motivation and social opportunity factors.

In addition to improved service provision and strengthened vaccine supply, communication-related recommendations include:

• Research has found that the family doctor is central in shaping people’s vaccination behaviour, and there is a need to build their skills to advise parents, respond to safety concerns and questions, and provide the necessary information and reassurance.
• Interventions are needed - e.g., engaging trusted stakeholders in enhancing confidence in vaccination - to build trust and social forms in favour of vaccination among well-educated caregivers.

The study exposed a need for more in-depth insights, including into the quality and convenience of services, and so has informed the design of an observation study with family practices serving vulnerable communities.