Vaccinating Roma children in Bulgaria

A new tool to reach vulnerable communities

April 2013

WHO’s innovative new "Guide to Tailoring Immunization Programmes", successfully pilot tested in Bulgaria, is helping countries reach children in vulnerable communities.

Nadezhda (“Hope”) is a settlement of 20 000 Roma people in southern Bulgaria. Families in Nadezhda live close together, in an area roughly the size of a dozen football fields, without proper sanitation and hygiene.

Dr Stefan Panayotov visits families in Nadezhda, Bulgaria.
WHO/E. Tontcheva

During a measles outbreak in Bulgaria in 2009-2010, more than 24 000 children fell sick, 90% of whom were from Roma communities, and 24 died. The children became infected because they had not been vaccinated, and because their living conditions made transmission too easy.

The authorities responded swiftly with an immunization campaign that protected almost 200 000 previously unvaccinated children. This stopped the outbreak. But the uptake of vaccines to protect against diseases like measles, diphtheria, polio and rubella remains lower in Roma communities like Nadezhda than it is among the general population.

Pilot using innovative WHO guide

To help countries improve vaccine coverage among vulnerable communities, WHO’s European Regional Office developed a Guide to Tailoring Immunization Programmes. It provides proven methods and tools to identify at-risk and vulnerable populations, determine barriers to vaccination, and implement evidence-based interventions to address those barriers.

"The Guide has helped us to understand the root of the problem and what needs to be done to fix it."

Emilia Tontcheva, Head of WHO’s Bulgaria Country Office

In 2012, the Guide was pilot tested among six Roma communities—one of them Nadezhda—in collaboration with the Bulgarian Ministry of Health, the National Centre for Infectious and Parasitic Diseases and local civil society organizations.

“Vaccine coverage in Bulgaria is generally high, above 95%, but some groups within the population, especially ethnic minorities, aren’t as well protected,” said Emilia Tontcheva, Head of WHO’s Country Office in Bulgaria. “The Guide has helped us to understand the root of the problem and what needs to be done to fix it. No child should have to remain at risk.”

The pilot test found that while the children in these communities received their first vaccines in hospital right after birth, many were missing out on the follow-up vaccines that are usually given at 12 months and older.

Lack of information about vaccinations

Girl in Nadezhda, Bulgaria.
WHO/E. Tontcheva

The research team discovered that parents and carers in these communities lacked information about the benefits of vaccination and about when they needed to take their children to health centres to receive vaccines on the national schedule.

In some cases, families were at a disadvantage because they lacked fluency in the Bulgarian language.

Poverty was also found to be a barrier for access to vaccination and health services. Even though childhood vaccines are provided for free in Bulgaria, for some families, even the cost of transportation to reach a health centre is beyond their budget.

General practitioners: trusted professionals

A key opportunity identified in the pilot study was the high level of trust placed in General Practitioners (GPs)—family doctors who are responsible for giving vaccines—by parents and carers in Roma communities. Many who were uncertain of the benefits or worried about the risks of vaccination were open to seeking advice from their GP.

Dr Radosveta Filipova, head of infectious disease control with the Bulgarian Ministry of Health, said “We welcomed the opportunity to pilot test the Guide and found it to be very practical. It has helped us to better understand the social, behavioural and environmental factors behind low vaccine coverage among some segments of our population. The next step will be to find ways of tailoring our programmes to meet their needs.”

Guide to be used in other European countries

Following the successful pilot in Bulgaria, other countries are now beginning to use the Guide. With support from WHO and in partnership with the European Centre for Disease Prevention and Control, Sweden is using it to examine and meet the needs of marginalized communities. Armenia is about to start using the Guide and a number of other countries have expressed interest.

“Simply telling people why they should vaccinate or giving them information and expecting them to act on it may not work if immunization programmes don’t understand the perspectives of the target population. We have to listen to parents, address their concerns, and help them understand what their children will gain from being vaccinated. The Guide we have developed and the support we’re giving countries to apply it should help strengthen their capacity to do that,” said Robb Butler, Technical Officer for Vaccine Preventable Diseases and Immunization in WHO’s European Regional Office.

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