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J Migr Health
J Migr Health
Journal of Migration and Health
2666-6235
Elsevier

S2666-6235(24)00009-6
10.1016/j.jmh.2024.100219
100219
Article
Knowledge and attitudes of healthcare personnel about vaccination of migrant and refugee children and adolescents
Ouzounidou Z a
Maltezou HC b
Chrysoula K c
Polysiou E d
Christofilea O e
Dounias G e
Pavli A androulapavli2017@gmail.com
f⁎
a Regional Department of Public Health of Cyclades, Greece
b Directorate of Research, Studies, and Documentation, National Public Health Organization, Athens, Greece
c School of Law, National Kapodistrian University of Athens, Greece
d Medical Intervention, Athens, Greece
e Department of Public Policy, Public Health School, University of West Attica, Athens, Greece
f Department of Travel Medicine, National Public Health Organization, 3-5 Agrafon Street, Athens 15123, Greece
⁎ Corresponding author. androulapavli2017@gmail.com
27 2 2024
2024
27 2 2024
9 10021915 11 2021
4 2 2024
26 2 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Background

The number of migrants to Greece has increased considerably the last decade. This study assessed the knowledge and attitudes of healthcare personnel (HCP) toward vaccination of newly-arrived children and adolescents in the Aegean islands, a major port of entry of migrants and refugees to Europe.

Methods

The study was conducted from September 2020 to January 2021. All (166) HCP employed in the public health sector of the Aegean islands were invited to participate. A structured questionnaire was used to collect demographic data and data about their knowledge and attitudes toward vaccinations for migrant and refugees.

Results

A total of 120 HCP participated (72 % response rate), including 54 (45 %) physicians, 43 nurses (35.8 %), and 23 health visitors (19.2 %). Sixty-seven (55.8 %) HCP were aware of the national vaccination guidelines. Health visitors had higher rates of knowledge about the national vaccination guidelines, compared with nurses and physicians (87% versus 44,2% and 51,9%; p-value-0.001). Overall, 73 (60.8 %) HCP were aware of vaccinations during the first examination upon arrival. Primary-healthcare physicians were more likely to be aware about the time of vaccine administration compared with hospital-based physicians (74 % versus 50 %; p-value = 0.006). Out of 120 HCP, 45 % knew that vaccination guidelines apply to all newly-arrived migrant and refugees and 65 % that vaccinations are free-of-charge. Overall, 67.5 % of participants supported no serology testing before vaccination, 21.8 % were against free-of-charge vaccinations, and 55 % recommended only priority vaccinations.

Conclusions

There is a need to increase HCP’ awareness and knowledge through training programs and tailored protocols focusing on vaccinations for newly-arrived migrant and refugee children and adolescents in order to promote effective vaccination of this vulnerable population.

Keywords

Vaccination
Immunization
Children
Adolescents
Refugees
Migrants
Knowledge
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pmcIntroduction

International migration has increased significantly over the past decades. According to the International Organization of Migration estimates, the number of international migrants was 272 million in 2019, which equates to 3.5 % of human population globally (International Organization of Migration, 2024). Migration to European Union/European Economic Area (EU/EEA), a major destination for international migrants, has increased considerably in recent years; currently migrants account for nearly 10 % of the European population. During the past decade the Aegean islands in Greece had received a large number of migrants, mainly from Afghanistan, the Syrian Arabic Republic, the State of Palestine, Iraq, and Pakistan; currently the Aegean islands constitute a major port of entry of migrants to Europe (United Nations High Commissioner for Refugees, 2024; Eurostat. Statistics explained, 2024; Pavli and Maltezou, 2017).

Migration has a significant impact on the epidemiology of infectious diseases, including vaccine-preventable diseases (Eurostat. Statistics explained, 2024; Pavli and Maltezou, 2017). A large number of migrants and refugees are not immunized or are incompletely immunized as a result of war, breakdown of healthcare systems, poverty, and population movement (Pavli and Maltezou, 2017), and therefore remain vulnerable to vaccine-preventable diseases (Pavli and Maltezou, 2017; Williams et al., 2016; Jones et al., 2016). This may have implications of public health importance (Williams et al., 2016; Jones et al., 2016). Equity in timely access to vaccinations through the implementation of vaccination programs that are integrated into routine healthcare services targeting migrants and refugees is a key measure to protect them and also to contribute to the national goals for prevention and control of vaccine-preventable diseases across Europe (Oliver and Mossialos, 2004; WHO, 2024).

In order to fulfill the need for guidance on effective screening and vaccination of newly-arrived migrants and refugees within the EU/EEA, the European Centre for Disease Control and Prevention published evidence-based guidelines and prioritized vaccinations for this group. The main objective of these guidelines is to support the EU/EEA Member States to develop national strategies to strengthen infectious disease prevention and control among migrants and meet the health needs of these populations (European Center for Disease Control and Prevention, 2018). However, there is considerable variation in vaccination policies for migrants and refugees across Europe and a lack of clarity on optimum ways forward. Nonetheless, it is crucial to ensure that migrant-specific guidelines are disseminated to front-line HCP in order to improve vaccine delivery and uptake by diverse migration populations across the region (Ravensbergen et al., 2019). In Greece, the national vaccination guidelines for migrants and refugees are based on the circular of the Hellenic Ministry of Health which includes vaccinations already included in the routine National Vaccination Program (Ravensbergen et al., 2019).

The purpose of this study was to assess the knowledge and attitudes of HCP employed in public healthcare facilities of the North and South Aegean islands, toward the national vaccination guidelines for newly-arrived migrant and refugee children and adolescents. In addition, this study can provide insights to improve the vaccination guidelines and develop vaccination strategies for this vulnerable population.

Methods

The study was carried out from September 2020 to January 2021 in the North and South Aegean islands. All 166 HCP of the public sector were invited to participate in the survey based on their area of practice and their engagement in providing healthcare services to migrants and refugees. In particular, invited HCP included pediatricians, internists, general practitioners, nurses, midwives, and health visitors who provide vaccination services in hospitals, primary healthcare centers, and rural healthcare centers of the public sector. Responders were validated through personal communication to confirm their HCP status. Ethical approval for the study was given by the Administration of Piraeus and Aegean Islands Health Distinct.

We used a structured questionnaire adapted from the questionnaire of a recent study of the European Society of Clinical Microbiology and Infectious Diseases (Ravensbergen et al., 2019). The original questionnaire was translated in the Greek language using a similar infrastructure (Ravensbergen et al., 2019). The questionnaire included questions about HCP demographics and occupational data and questions about the National Vaccination Program of Greece (National Vaccination Program for Children and Adolescents, 2024). The HCP’ knowledge about the national vaccination guidelines for migrants and refugees as well as their attitudes towards vaccinations were also recorded and assessed (World Health Organization, 2006). The questionnaire was distributed online, along with a consent form which was requested from all participants. A pilot study was conducted among 20 randomly selected HCP employed in the participating healthcare facilities.

The HCP’ knowledge was assessed based on the national guidelines for vaccinations of newly-arrived migrants and refugees in Greece (Table 1) (Hellenic Ministry of Health, 2021). High knowledge score was defined as correct answers regarding all recommended vaccines including, measles-mumps-rubella (MMR) vaccine, diphtheria, tetanus, acellular pertussis, inactivated poliomyelitis (DTaP-IPV) vaccine or diphtheria, tetanus, acellular pertussis, inactivated poliomyelitis Haemophilus influenzae type B (DTaP-IPV-Hib) vaccine or diphtheria, tetanus, acellular pertussis, inactivated poliomyelitis, Haemophilus influenzae type B, hepatitis B (DTaP-IPV-Hib-HepB) vaccine, and bacillus Calmette-Guerin (BCG) vaccine. Average and low knowledge scores were defined as correct answers of only 3 and of 2 or less of the recommended vaccines, respectively.Table 1 Recommendations for migrants/refugees’ vaccinations at points of care (Circular of Ministry of Health) (World Health Organization, 2006).

Table 1Vaccine	Newborns	6w-4 y	>4 y	2m-5 y	≥ 6m	12m-< 15 y	During outbreaks	
BCG	+							
DTaP-IPV		+	+					
DTaP-IPV-Hib		+						
DTaP-IPV–Hib-Hep B		+						
MMR (1 dose)						+		
Pneumococcal vaccine				+				
Influenza vaccine					+		+	
Meningococcal vaccine A, C, W135, Y							+	
BCG: Bacille Calmette-Guerin.

DTaP-IPV–Hib-Hep B: diphtheria-tetanus-acellular pertussis-inactivated poliomyelitis-Hemophilus influenzae b-hepatitis B.

MMR: measles-mumps-rubella.

w: week/s, m: month/s, y: year/s.

HCP were defined as persons engaged in the provision of healthcare services in structured healthcare facilities (hospitals, primary healthcare centers, and rural healthcare centers) (Hellenic Ministry of Health, 2021). Migrant groups included: recently-arrived migrants, defined as foreign-born, residing in the host country for less than 10 years; refugees, defined as those granted asylum; asylum seekers, defined as those awaiting a decision after applying for asylum in the host country; and undocumented or irregular migrants as those without necessary authorization or documents under the host country's immigration regulations.

Frequency tables were used to describe the categorical data while mean ± standard deviation (SD) was used to describe the continuous data. The analysis techniques used contingency tables which display the frequency distribution of the variables. Chi-square (x2) tests were used to estimate the correlation between different variables to determine whether or not there is a dependency between them. P-values ≤ 0.05 were considered statistically significant. The statistical package IBM SPSS Statistics 24 was used for the statistical analysis.

Results

A total of 120 out of 166 invited HCP participated in the study (response rate: 72 %). Table 2 describes the characteristics of the participating HCP. There were 54 physicians, 43 nurses, and 23 health visitors (45 %, 35,8 %, and 19,2 %, respectively). Most of the participating HCP (90 %) were ≤55 years of age, practicing in the South Aegean islands (62.5 %), and in hospitals (55 %).Table 2 Characteristics of healthcare personnel (N = 120).

Table 2Characteristic	N (%)		
Mean age, years (range)		41.73 (24–63)	
Median age, years (range)		42 (24–63)	
Gender			
Female	85 (70.8)		
Male	35 (29.2)		
Specialty			
Physician	54 (45)		
Nurse	43 (35.8)		
Health visitor	23 (19.2)		
Area of Practice			
North Aegean islands	75 (62.5)		
South Aegean islands	45 (37.5)		
Healthcare facility			
Hospital	66 (55)		
Primary healthcare center	54 (45)		
Duration of practice			
Mean duration, years (range)		10.74 (1–37)	
Median duration, years (range)		10 (1–37)	

Table 3 shows the knowledge and attitudes of HCP about the national vaccination guidelines in Greece for migrant and refugee children and adolescents and their implementation, by category of occupation. Only 67 HCP (55.8 %) were aware of the national vaccination guidelines while 21 (17.5 %) ignored them and 32 (26.7 %) did not answer. Among HCP, health visitors had significantly higher rates of knowledge about the national vaccination guidelines, followed by nurses and physicians (87 % versus 44.2 % and 51.9 %, respectively; p-value = 0.001). Ninety-six (80 %) HCP knew about the medical examination of migrants and refugees provided upon arrival; HCP of the North Aegean islands were more likely to know about the assessment of past vaccinations during this examination compared to those of the South Aegean islands (95.6 % versus 70.7 %; p = 0.004). Approximately 60 % of HCP knew that vaccinations were administered during the first examination. Considering the total number of physicians (primary care and hospital-based), primary healthcare physicians were more likely to be aware of the administration of vaccinations during the first medical examination than their hospital counterparts (74 % versus 50 %; p = 0.006). Regarding the target migrant population, 26.7 %, 22.5 %, and 5.8 % of HCP stated that vaccination guidelines apply only to refugees or asylum seekers, any group of migrants and refugees, and undocumented migrants, respectively. Other variables considered for knowledge (e.g. specialty, area of practice) the differences were not statistically significant (Table 3).Table 3 Knowledge and attitudes of healthcare personnel about national guidelines of vaccination for migrant and refugee children and adolescents and their implementation.

Table 3	Physicians N = 54	Nurses N = 43	Health visitors N = 23	Total*N = 120	P < 0.05	
Ν (%)⁎⁎	
Knowledge about national guidelines regarding vaccination	28 (51.9)	19 (44.2)	20 (87)	67 (55.8)	0.001	
Knowledge of the medical examination by primary care professionals on arrival	–	–	–	96 (80)⁎⁎⁎	0.004	
⁎⁎⁎⁎Knowledge of administration of vaccines during the first medical examination by primary healthcare professionals	33 (61.1)	15 (34.8)	6 (26)	54 (45)	0.005	
⁎⁎⁎⁎Knowledge of administration of vaccines during first medical examination by hospital healthcare professionals	21 (31.8)	28 (65.1)	17 (73.9)	66 (55)	0.005	
Knowledge about administration of recommended priority vaccines to newly-arrived migrant and refugees children and adolescents	21 (38.9)	18 (41.9)	15 (65.2)	54 (45)	0.031	
⁎⁎⁎⁎⁎Knowledge about migrant and refugee provision of free of charge vaccines	31 (57.4)	26 (60.5)	21 (91.3)	78 (65)	0.013	
Negative attitude regarding serology tests prior to vaccination	42 (77.8)	22 (51.2)	17 (73.9)	81 (67.5)	0.016	
Negative attitude regarding provision of free-of-charge vaccinations to all newly-arrived migrant and refugees	7 (23.3)	3 (17.6)	2 (25)	12 (21.8)	0.019	
Negative attitude regarding provision of free-of-charge vaccinations to undocumented migrant and refugees	18 (60)	8 (47.1)	1 (12.5)	27 (49.1)	0.019	
Positive attitude of healthcare personnel regarding the adequacy of recommended vaccines for migrant and refugee children and adolescents	7 (13)	0 (0)	0 (0)	7 (5.8)	0.011	
⁎ The numbers and percentages corresponding to each question (under the column of Total N = 120) are refer to the total number of HCP (120).

⁎⁎ The numbers and percentages corresponding to each question are referred to the total number of HCP according to their profession (physicians, nurses, health visitors).

⁎⁎⁎ Medical examination is only performed by physicians.

⁎⁎⁎⁎ This variable “referred to HCP's general knowledge about the time of administering the priority vaccines that is during the first medical examination.

⁎⁎⁎⁎⁎ Knowledge about providing vaccines free of charge may be different from knowledge about indication for administration of vaccines.

Regarding HCP’ attitudes, 70 % of them supported the development of national vaccination guidelines for migrant and refugee children. Female HCP were more likely to agree than male HCP (75.3 % versus 57.1 %; p = 0.041). In regards to the setting of vaccination, 47.5 % of HCP stated that vaccines should be administered at reception centers, refugee camps and detention centers, 28.3 % at their country of origin, 21.7 % at the point of entry, and 2.5 % after provision of asylum. The majority of HCPs (67.5 %) had a negative attitude regarding serology testing before vaccination. Nearly half of them were against administering vaccines free of charge to undocumented migrants and refugees and 21.8 % of them only to all newly arrived migrants and refugees. Table 4 shows the knowledge about the recommendation of each type of vaccine. In particular, regarding each type of vaccine for newly-arrived migrants and refugee children and adolescents, 65 (54.2 %) and 66 (55 %) of HCP recommended only priority vaccines, whereas 40 (33.3 %) and 36 (30 %) of them recommended all vaccines according to the National Vaccination Program, respectively. Vaccines such as DTaP (46.7 %), Hib (45 %), Hep B (45 %), and MMR (44.2 %) were more commonly recommended for children, while DTaP (60 %), meningococcal (40 %), human papillomavirus (HPV) (40 %), and IPV (36.7 %) for adolescents (Table 4);.Table 4 Knowledge of healthcare personnel about the recommendation (indication) of each type of vaccine for migrant and refugee children and adolescents.

Table 4Vaccines	Children (0–12 years) N (%)	Adolescents (13–18 years) N (%)	
Priority vaccines			
BCG	50 (41.7)	38 (31.7)	
DTaP	56 (46.7)	60 (60)	
MMR (1 dose)	53 (44.2)	38 (31.7)	
IPV	46 (38.3)	44 (36.7)	
Hep A	50 (41.7)	36 (30)	
Hib	54 (45)	42 (35)	
Hep B	54 (45)	42 (35)	
Other vaccines*			
Pneumococcal	44 (36.7)	37 (30.8)	
Influenza	43 (35.8)	35 (29.2)	
Varicella	46 (38.3)	29 (24.2)	
Meningococcal (A,C,W135,Y)	53 (44.2)	48 (40)	
HPV	30 (25)	48 (40)	
BCG: bacillus Calmette-Guerin.

DTaP: tetanus-diphtheria-acellular pertussis.

IPV: poliomyelitis.

Hib: Hemophilus influenzae b.

Hep B: hepatitis B.

HPV: human papilloma virus.

MMR: measles, mumps, rubella.

⁎ included in the National Vaccination Program for Children and Adolescents, available at https://www.moh.gov.gr/articles/health/dieythynsh-dhmosias-ygieinhs/emboliasmoi/ethniko-programma-emboliasmwn-epe-paidiwn-kai-efhbwn/ (in Greek) [accessed 4/2/2024].

Lastly, the rate of knowledge of HCP about the recommended priority vaccinations for migrant and refugee children was assessed as high, average, and low in 35 %, 45 %, and 10.8 % of them, respectively. The rate of their knowledge about priority vaccinations for adolescents was assessed as high, average, and low for 36.7 %, 16.7 %, and 20 %, respectively, whereas 9.2 % and 26.6 % stated that they had no knowledge at all about vaccination guidelines for children and adolescents, respectively.

Discussion

The present study was carried out to assess the knowledge and attitudes of HCP working in public healthcare facilities in the North and South Aegean islands regarding vaccinations for newly-arrived migrant and refugee children and adolescents. To the best of our knowledge, there has been no other similar Greek study. The results revealed heterogeneity of knowledge and attitudes among the participating HCP. The Aegean Sea islands in Greece have received a disproportionate burden and responsibility in hosting this vulnerable population (UNHCR, 2024). Migrant populations may suffer a significant burden of infectious diseases due to poor conditions in their countries of origin or during movement to the host country (European Center for Disease Control and Prevention, 2024). Moreover, the majority of migrants and refugees have an unknown vaccination status, which makes their vaccination approach even more difficult.

Given the rising migration to Europe, vaccinations of migrant populations have become a public health priority; moreover, several European countries are committed to extend the benefits of vaccinations for all. Vaccination of migrants and refugees in Greece is based on the Hellenic national vaccination guidelines for newly-arrived migrants and refugees (European Center for Disease Control and Prevention, 2018; Hellenic Ministry of Health, 2021; Noori et al., 2021). Vaccination services for migrant and refugee children and adolescents in Greece have been mainly provided by non-governmental organizations (NGOs) and the National Public Health Organization under the coordination of the Hellenic Ministry of Health and to a lesser extent by the local HCP. This has resulted in lack of harmonization of vaccination practices and heterogeneity of vaccination coverage among them (National School of Public Health, 2017; Mellou et al., 2019).

The European Vaccine Action Plan 2015–2020 was developed by the World Health Organization European Region with a vision of a European Region free from vaccine-preventable diseases and with equity of access to high-quality, safe, and affordable vaccines and vaccination services throughout life (Mellou et al., 2019). Although the action plan highlighted the importance of reducing inequities and monitoring performance in underserved groups including migrants and refugees, data from European countries and catch-up policies are limited and vary by country (World Health Organization, 2024).

The heterogeneity of HCP’ knowledge and attitudes regarding the vaccination of migrant and refugee children and adolescents which was revealed by the present study has been also found among HCP who provide healthcare to migrant patients in France and Denmark (Moussaoui et al., 2021; Nakken et al., 2018). This heterogeneity may be related to the lack of vaccination documentation, lack of awareness and ability to follow the national vaccination guidelines, differences in local catch-up vaccination strategies, as well as lack of harmonization of implementation of vaccinations for these vulnerable populations (Nakken et al., 2018). However, in a Norwegian study it was revealed that HCP were aware and agreed that vaccinations of migrant children, which are included in the national vaccination schedule, function well and capture all children (Socha and Klein, 2020).

In the present study, the low knowledge score of HCP about the national guidelines and their implementation to all newly-arrived migrant and refugee children and adolescents may be attributed to their limited involvement in vaccinations to them as well as to gaps in clear guidance at a national or regional level (National School of Public Health, 2017; Mellou et al., 2019). Overall, HCP employed in the North Aegean islands had higher levels of knowledge compared with HCP in the Southern Aegean islands, which is explained by the fact that the North Aegean islands account for most newly-arrived migrants and refugees in Greece. However, the majority of HCP was aware of the first medical examination the vaccination assessment upon arrival, and the administration of vaccinations which is carried out by physicians at that time as well as the provision of them free of charge. Similar information was reported by HCP in the Danish study too (Nakken et al., 2018). Improving HCP’ awareness of vaccination requirements in different regions globally may positively influence the knowledge and attitudes of HCP who provide vaccination services to new migrants in Greece (World Health Organization, 2024; Moussaoui et al., 2021; Nakken et al., 2018).

In the present study, approximately one-third of participating HCP accepted serology testing in cases of doubt as the favored solution for vaccination assessment. This may be due to fear of increased risks associated with the over and frequent administration of certain vaccines due to lack of vaccination documentation (Moussaoui et al., 2021; Nakken et al., 2018; de Monléon et al., 2014). However, the majority of HCP and in particular physicians supported no serology testing prior to vaccination. This was partly similar to the French general practitioners’ approach who recommend serology testing only for hepatitis B, and the Canadian and the United States Centers for Disease Control and Prevention recommendations for newly-arrived migrants originating from countries with a HBsAg prevalence of ≥2 % (Moussaoui et al., 2021; Vie le Sage et al., 2019). A recent systematic review showed no evidence of the cost-benefit of performing pre-vaccination serological testing against vaccine-preventable diseases (Hui et al., 2018).

In our study, less than half of HCP stated that vaccination should be carried out in the reception centers, refugee camps, and detention centers, a recommendation which is in line with policies and practices in EU/EEA countries (Giambi et al., 2019); however, nearly one-third of them supported the provision of vaccination at the country of origin. These findings, as shown by others (Moussaoui et al., 2021; Nakken et al., 2018), indicate a need for educating HCP on the way to determine the vaccination needs of migrant children and access to relevant and continuing updated information. In addition, it is crucial for HCP to understand factors contributing to interruptions of the vaccinations in the home countries of newly-arrived migrants and refugees, as well as lack of access to vaccination services during migration (Moussaoui et al., 2021; Nakken et al., 2018; Socha and Klein, 2020). Free-of-charge vaccination of all migrants and refugees was supported by most HCP; however, nearly half of the non-supporters recommended that undocumented migrants and refugees should be charged. Similar views have been reported in other studies (Hargreaves et al., 2018).

Increased motivation and interest as well as regular engagement in preventive vaccination may explain the primary HCP’ higher knowledge scores about the administration of vaccinations during the first medical examination and vaccination assessment compared with those of hospital-based HCP (Tsiligianni et al., 2020). Primary healthcare physicians have played a crucial role in delivering vaccinations globally, which underlines their key role in the provision of vaccination counseling and vaccinations to migrant and refugee children (Wilkinson et al., 2021; Kalemaki et al., 2020). Lastly, the majority of HCP in the present study considered that the national vaccination guidelines for migrant children are inadequate, and also recommended the development of vaccination strategies to overcome these difficulties. Such strategies should include specific migrant-tailored guidelines, full access to the National Vaccination Program with low or no cost, and serology testing, if required, through the healthcare system. Vaccination registries should also be developed. These findings are in line with the results of other relevant studies among HCP (Mipatrini et al., 2017).

Strengths and limitations

A clear strength of our study is the prospective collection of data from HCP involved in the management of migrant and refugee children in an area of Greece which is one of the main points of entry for migrants and refugees in Europe. This is a novel cross-sectional observational study in the region in which it was conducted. To our knowledge, there is no other similar study. The main limitation of the study includes selection bias. Our study provides a brief snapshot into HCP knowledge and attitudes regarding the vaccination of migrant and refugee children and adolescents, in the public sector of particular areas with a high concentration of newly-arrived migrant and refugee populations. Thus, our findings cannot be generalized to all HCP in Greece. In addition, those who are exclusively engaged in the management of these populations such as those representing NGOs and the National Public Health Organization did not participate in the survey. Lastly, our findings may not apply to other settings because of variations in the structure and delivery of healthcare services for migrant and refugee children and adolescents.

Conclusions

This is one of few studies assessing the knowledge and attitudes of HCP regarding vaccination of migrant and refugee children and adolescents in a host country. Our study revealed inadequate knowledge and heterogeneity among participating HCP. Educational campaigns and access to national vaccination guidelines are needed to increase vaccination awareness among HCP. Vaccination registries for migrants and refugees are needed to secure reliable vaccination documentation. Coordination between stakeholders is also important to facilitate implementation of adequate and effective vaccination programs for migrant and refugee children and adolescents.

Funding

No funding was received for this study.

CRediT authorship contribution statement

Z Ouzounidou: Writing – original draft, Investigation, Formal analysis, Data curation. HC Maltezou: Writing – review & editing, Investigation, Formal analysis. K Chrysoula: Writing – review & editing, Investigation. E Polysiou: Writing – review & editing, Investigation. O Christofilea: Writing – review & editing, Investigation, Data curation. G Dounias: Writing – review & editing, Supervision, Formal analysis, Conceptualization. A Pavli: Writing – original draft, Supervision, Formal analysis, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

We thank all healthcare workers from primary care centers and hospitals of the National Health System from North and South Aegean who participated in the current study for their contribution. We also thank Dr Sofanne J. Ravensbergen, from the Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Center Groningen, for her permission to use and adapt the questionnaire of the European Society of Clinical Microbiology and Infectious Diseases, in order to conduct this study.
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