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Page 1 Page 2 A lie can travel halfway around the world while the truth is putting on its shoes. Mark Twains quote is more relevant than ever in times of online communication, where information or misinformation, bundled in bits and bytes, streams around the earth within seconds. SUMMARY DISCLAIMERUNICEF working papers aim to facilitate greater exchange of knowledge and stimulate analytical discussion on an issue. This text has not been edited to official publications standards. Extracts from this paper may be freely reproduced with due acknowledgement. For the purposes of this research, no personal data has been extracted and stored for data collection and analysis. This UNICEF working paper aims to track and analyse online anti-vaccination sentiment in social media networks by examining conversations across social media in English, Russian, Romanian and Polish. The findings support the assumption that parents actively use social networks and blogs to inform their decisions on vaccinating their children. The paper proposes a research model that detects and clusters commonly-used keywords and intensity of user interaction. The end goal is the development of targeted and efficient engagement strategies for health and communication experts in the field as well as for partner organisations. Page 3 CONTENT1. Rationale 2. Introduction 2.1 Social Media: the conversation shift 2.2 Social Media: Fertile ground for anti- vaccination sentiment 2.3 Social Media Monitoring 2.4 Influencers 3. Research Objectives 4. Methodology 4.1 Descriptive and Explorative Research Design 4.2 Data Collection 4.3 Limitations 4.4 Ethical Considerations 5. Empirical Findings 5.1 Networks: Volume and Engagement 5.2 Common Arguments 5.2.1 Religious and Ethical Beliefs 5.2.2 Side Effects 5.2.3 Development Disabilities 5.2.4 Chemicals, Toxins and Unnecessary 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest 5.3 Influencers 6. Discussion and Recommendations 6.1 Discussion 6.2 Recommendation Acknowledgements Literature Appendix 4 555 78 9 1111121313 1414191920212222 23 252527 313134 Page 4 Over the past few years, the region of Central and Eastern Europe and the Commonwealth of Independent States has been troubled by the rise of a strong anti-vaccine sentiment, particularly via the internet. Wide ranging in origin, motive, source, and specific objectives, this online sentiment has succeeded in influencing the vaccination decisions of young parents, in many instances negatively. A number of factors are at play in this online anti-vaccine sentiment. First, vaccination coverage in this region is generally high. As a result, vaccine-preventable childhood diseases like polio and measles have been absent in most countries for the past few decades. This has led to complacency toward the diseases and has unfortunately made vaccines, rather than the diseases, the focus of debate and discussion. Meanwhile, poorly-managed immunization campaigns in some countries have caused widespread mistrust of vaccines and government vaccination programs. Most countries have run sluggish, high-handed public communication campaigns while avoiding transparent dialogue with the public on possible side effects, coincidental adverse events and other safety issues. Moreover, when new vaccines have been introduced, they have often just exacerbated the publics existing doubts, hesitations or outright resistance. Into this mix, rapid penetration of the internet in the region has provided a powerful, pervasive platform for anti-vaccine messages to be disseminated. Rooted in scientific and pseudo-scientific online sources of information, messages are often manipulated and misinterpreted, undermining the confidence of parents and causing them to question the need for, and efficiency of, vaccines. The result is hesitation towards vaccination, which in large numbers poses a serious threat to the health and rights of children.This paper aims to examine this rapidly growing phenomenon and its global lessons. Depending on the nature of the problem, special strategies need to be developed to tactically address and counter, diffuse or mitigate its impact on ordinary parents. The prevailing approach of most governments in largely ignoring these forces is unlikely to address this growing phenomenon. Governments, international agencies and other partners - in particular the medical community - need to combine forces to identify the source and arguments of these online influences, map the extent to which they control negative decisions, develop more effective communication strategies and ultimately reverse this counterproductive trend. RATIONALE Page 5 The first part of this paper describes how anti-vaccination groups communicate and how social networks connect concerned parents in new ways. The second part emphasizes the role of social media monitoring in strategic communication, based on understanding audience needs. 2.1 Social media: The conversation shifts The rise of social networks has changed both the way we communicate and the way we consume information. Even within the relatively recent internet era, a major evolution has occurred: In the initial phase known as Web 1.0, users by-and-large consumed online information passively. Now, in the age of social media and Web 2.0, the internet is increasingly used for participation, interaction, conversation and community building1. At the same time, conversations or social interactions that used to occur in community centres, streets, markets and households have partly shifted to social media2. Parents, for instance, suddenly have an array of collaborative social media tools with which to create, edit, upload and share opinions with their friends, peers and the wider community. These conversations are recorded, archived and publicly available. 2.2 Social media: Fertile ground for anti-vaccination sentiment In todays information age, anyone with access to the internet can publish their thoughts and opinions. On health matters in particular, the public increasingly searches online for information to support or counter specialised, expert knowledge in medicine3. Due to the open nature of user participation, health messages, concerns and misinformation can spread across the globe in a rapid, efficient manner4. In this way, social media may influence vaccination decisions by delivering both scientific and pseudo-scientific information that alters the perceived personal risk of both vaccine-preventable diseases and vaccination side effects. INTRODUCTION 1 Constantinides et al, 2007 2 Phillips et al, 2009; Brown, 2009 3 Kata, 2012 4 Betsch et al, 2012 Page 6 In addition to this accelerated flow of information (whether accurate or not), social media messages tend to resonate particularly well among users who read or post personal stories that contain high emotional appeal. This holds true for anti-vaccination messages too. In other words, both logistically and qualitatively, social media is intensifying the reach and power of anti-vaccination messages. Negative reactions to vaccines are increasingly being shared across online platforms. All of this leads to a frustrating predicament and critical challenge: Immunizations protect people from deadly, contagious diseases such as measles, whooping cough and polio. But parents influenced by anti-vaccination sentiment often believe vaccines cause autism, brain damage, HIV and other conditions, and have begun refusing them for their children. As a consequence, health workers face misinformed, angry parents, and countries face outbreaks of out-dated diseases and preventable childhood deaths5. Why do anti-vaccination messages resonate with so many parents in the first place? Parental hesitation regarding vaccinations is thought to stem from two key emotions: fear and distrust: Vaccination is a scary act for many children and parents. A biological agent is injected into the child. The way the biological agent works in the childs body is for most people unclear, which appeals to parents fears. The high level of distrust stems from the intersection of government, medicine and pharmaceutical industry. The nature of its act and the fact that vaccinations are mostly compulsory leads to worries among citizens. (Seth Mnookin, 2011) This distrust, along with the interactive nature of social media, suggests an urgent need for health workers to become attuned to arguments and concerns of parents in different locations and of various cultural backgrounds. To achieve more synergistic relationships with an audience, organisations need to shift their communications strategy from getting attention to giving attention6. Compounding this challenge is the fact that some anti-vaccination groups are not merely sceptics or devils advocates, but operate in an organized, deliberate and even ideological manner. These anti-vaccination groups often employ heavy-handed 5 Melnick, 20116 Chaffrey et al, 2008 Page 7 communication tactics when dealing with opponents: they delete critical comments on controlled media channels, such as blogs7 ; they mobilize to complain about scientists and writers critical of their cause; sometimes they go going as far as to take legal action to prohibit the publishing of pro-vaccine material. Governments and organisations aim to keep parents accurately informed about vaccinating their children. As more of the public conversation indeed battle takes place across social media, there is an urgent need to understand this online landscape. This, in turn, requires the use of effective monitoring tools. 2.3 Social media monitoring Social media analysis plays an important strategic role in understanding new forms of user-generated content8 . Indeed, this type of monitoring has become a leading trend in Marketing, PR, political campaigns, financial markets and other sectors. As demand for this kind of data increases, more monitoring tools are becoming available. These tools search social networks for relevant content, and archive the publicly available conversation in a database. Researchers conduct their internet analysis primarily by formulating combinations of keywords that can be placed in relation and weighted for importance. There are four different types of social media monitoring: Monitoring by volume looks at the amount of mentions, views and posts a topic, organization or user receives. Monitoring by channels maps and examines the various networks that users use to exchange content. Monitoring by engagement seeks deeper insight into how many users actually respond, like, share and participate with the content. Monitoring by sentiment analysis is a qualitative approach that uses word libraries to detect positive or negative attitudes by users towards an issue9. The first phase in social media monitoring is listening to what users say, because in order, for instance, to engage effectively with parents on social networks, it is important to know what they are talking about10. 7 Kata, 2012 8 Cooke et al, 2008 9 The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. 10 Kotler et al, 2007 Page 8 Social media monitoring is a young discipline that began just a few years ago, and in its initial phase the practice faced a number of challenges. Data was very complex, so first generation monitoring tools produced results that were unstructured and generally overwhelming11. Even when that data was sorted and structured, organizations struggled to generate actionable management recommendations from it12. Since that time, however, social media professionals and research communities have made steady progress in overcoming the early challenges. 2.4 Influencers Recent studies on social media networks emphasize the central role played by influential individuals in shaping attitudes and disseminating information13. Indeed, it is argued that a group of such influencers is responsible for driving trends, influencing public opinion and recommending products14. One study found that 78% of consumers trusted social peer recommendations, while just 14% trusted advertisements15. Intensive interaction and content sharing through social media means that an audience instinctively determines its own opinion leaders. What makes opinion leaders particularly interesting and important from our perspective is that they add their personal interpretation to the media content and pass it on to their audience. Depending on whether these influencers speak responsibly or not, this can have positive or negative impact on the goal of disseminating accurate information. In his book The Panic Virus, journalist Seth Mnookin offers some examples of controversial influencers: A British gastroenterologist, Andrew Wakefield, entered into the vaccine discourse and alleged that the measles-mumps-rubella vaccine might cause autism. The medical community eventually dispelled his arguments and he lost his medical license. For a decade Wakefield - though not a public health specialist - very successfully disseminated misleading information and garnered a significant social media following. Meanwhile, actress and model Jenny McCarthy has become another self-proclaimed expert on vaccine safety. Through frequent public appearances she has positioned herself as an 11 Wiesenfeld et al, 201012 Owyang et al, 201013 Tsang et al, 2005; Kiss et al, 2008; Bodendorf et al, 201014 Keller and Berry, 200315 Qualman, 2010 Page 9 educated, internet-savvy mother set on challenging the medical establishments information about vaccinations. This, too, has helped fuel the recent growth in anti-vaccination sentiments. The public following and authority gained by Wakefield and McCarthy demonstrate how with the proliferation of online channels and the user as the centre of attention, it becomes difficult for information seekers to differentiate between professional and amateur content16. By the time the record is set straight, trust in immunization is been partly destroyed. Fostering the positive opinion of influencers in communities can have a disproportionately large impact in terms of online reputation17. Though they may not know each other in the real world, and despite ever-expanding advertisement platforms and sources, consumers around the world still place their greatest trust in other consumers18. Audiences listen to opinion leaders because they are known to be independent, credible and loyal to their peers19. Identifying and influencing the influencers of the social media conversation in the region should therefore be part of any effective strategy to reinforce positive messages in the vaccination debate. Though the internet is increasingly used to search for health information, a number of questions about social media and vaccination decisions are still unanswered: Which channels are used by anti-vaccination groups? What are the key arguments and conversation themes? What makes anti-vaccination messages appealing to parents? Who are the opinion leaders in online discussions? What are the best strategies to respond to anti-vaccination arguments? This paper seeks to understand the internal dynamics of anti-vaccination sentiment in social media networks in Eastern RESEARCHOBJECTIVES 16 Cooke et al, 200817 Ryan et al, 200918 Nielsen, 200919 Weiman, 1994 Page 10 Europe20. These insights are expected to help health workers, partners and national governments to develop appropriate response strategies in order to convince the public of the value, effectiveness and safety of vaccinations. The objectives of this research are: 1. To monitor social media networks, consolidate existing data and information from partners. 2. To categorize and analyse conversation themes, based on volume of discussion, influence, engagement and audience demographic as appropriate. 3. To identify influencers in the different language groups and platforms. 4. To contribute to a set of recommended strategies to address specific anti-vaccine sentiment around the various conversation themes. This content analysis is expected to help us understand the motivations and mind sets behind the sentiment, and offer clues that can inform the development of a strategy to effectively address the phenomenon. The research is also expected to help drawing comparisons between the anti-vaccination sentiment phenomenon and similar sentiments expressed against interventions in nutrition, child protection and other areas of UNICEF practice. This paper is supported by UNICEF Department of Communication in New York and UNICEF Regional Office for Central and Eastern Europe and the Commonwealth of Independent States. The region covers 22 countries and territories: Albania, Armenia, Azer-baijan, Belarus, Bosnia & Herzegovina, Bulgaria, Croatia, Georgia, Kazakhstan, Kosovo (UN Administered region), Kyrgyzstan, TFYR Macedonia, Moldova, Montenegro, Roma-nia, The Russian Federation, Serbia, Tajikistan, Turkey, Turkmenistan, Ukraine, Uzbekistan. UNICEF does not have a country programme in the Russia Federation but is in discussions to develop a new mode of engagement. Page 11 In order to assess the dynamics of the anti-vaccination sentiments in the four languages, a systematic mapping and content analysis via social media monitoring is proposed. For the purpose of stakeholder monitoring in social media, a combination of descriptive and exploratory methods in form of quantitative and qualitative observation is proposed. According Wiesenfeld, Bush and Skidar (2010) it is reasonable to combine both methods because social media monitoring offers the richness of qualitative research, with the sample sizes of quantitative research. It may also give the opportunity to overcome problems associated with each research method in order to understand stakeholders dynamics in social media. 4.1 Descriptive and Explorative Research Design The descriptive methodology involves recording the activities of users and events in a systematic manner. Information is recorded as events occur and archived. Descriptive research in this case involves: Figure 1: Research Process for data gathering and analysis. METHODOLOGY 12 Aggregating text from public accessible social networks in in English, Russian, Polish and Romanian language. Cleaning and categorizing the data over time. The data is categorized and analysed into reoccurring conversation themes, based on volume of posts, engagement and audience demographic as appropriate. The exploratory methodology follows the descriptive research to allow for the interpretation of patterns and to provide background understanding of sentiment and attitudes of users. The results of the structured observation will be put into context by the human judgement of the researcher through the participant observation. In this research, the researcher will be a complete observer and will not interact with the users during the participant observation (Saunders et al, 2009). 4.2 Data Collection Traditional sampling techniques such as random, convenience or judgemental sampling are difficult to apply to a fluid social media environment. On top of the social media measurement process, the selected social media channels feed into the sample set. The posts are further categorized into different issue arenas that will be associated with relevant stakeholders. Figure 1 presents the data collection process for monitoring stakeholders in social media.The process contains the following six steps: 1. Channels: The first step of the data collection process involved the selection of relevant social media channels. Social media monitoring is instead generally considered to provide a complete set of all contributors, because tools like Radian6 or Sysomos are designed to capture a wide range of social media channels, such as blogs, forums, Twitter, Tumblr, Youtube and Facebook. 2. Demographics: The software gathered relevant posts that were posted in English, Russian, Polish and Romanian language3 during the period of 1 May and 30 July 2012. Posts could be submitted from all regions worldwide. 3. Context: The quality of data collection is determined by how well the collected data is gathered with regards to formulated searches. Keyword logic and search profiles were employed to filter the data. The full list of keyword combination can be found in Appendix A. 3The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. Page 13 4. Data Collection: Relevant social media mentions that contained an issue-related keyword in relation to a stakeholder-related keyword was archived in the database. The list of relevant mentions was stored chronologically and assigned an ID. The full list of exported information about each mention was stored in a separate EXCEL file. 5. Data Analysis: The empirical application and content analysis of the relevant posts can be found in Chapter 6. 4.3 Limitations There are limitations in terms of reliability and validity of the recorded data. The data collection covers a three-months period. There is a need for caution when generalizing the data because events and evolution of discussions may alter the findings in other time periods. Therefore, limitations in reliability refer to reproducibility of research results. Reliability in the extent to which measures are free from error and therefore provide consistent results, such as the consistency of data availability in social media monitoring, is the second limitations. Quantitative observation has relatively high reliability because it reduces the potential for observer bias and enhances the reliability of data (Malhorta et al, 2007). However, social media monitoring might carry the risk of monitoring bias, as the relevant posts are extracted through keyword logic that is developed by the researcher. The collected data cannot be regarded as complete. For example, the share of Russian-speaking discussions seems to be fairly low compared to the amount of users accessing social media. Governmental control and censorship might also be contributing for lower volumes.The external validity, which is defined as the extent to which the research results are applicable to other research settings (Malhotra et al, 2007), is relatively low. Because of the richness of data, the sampling needs to be based on the experience of the researcher. As a disadvantage, the lack of established sampling technique in social media limits the ability to generalize the findings to other relevant issue arenas or stakeholders in the population. However, the ability to generalize the results was enhanced by careful use of the theoretical terms and relationships in the stakeholder literature (especially Freeman, 1984; Mitchell et al, 1997; Luoma-aho et al, 2010; Owyang et al, 2010). 4.4 Ethical Considerations Monitoring social media conversations raises two important questions about a) the protection of privacy, and b) ethical concerns. The growth of interest in social media monitoring has Page 14 triggered a new debate about ethics, which centers on what is in the public domain and what is not (Poynter, 2010). Privacy is a big issue, and social networking sites are under public criticism for lax attitudes regarding the security and respect of users privacy (Wakefield, 2011). It is the responsibility of the market researcher to protect a respondents identity and not disclose it to external audiences (Malhotra et al, 2007). Social media monitoring offers a rich volume of data, however the Internet is largely unregulated. The data of users around the world is stored on servers in the US and completely available to the US authorities. What might seem legal to the researcher may not necessarily be deemed morally right by society. Public interactions in social media are available for anyone and can be assigned to a personal IP address, geographic location, language, date and even specific computer. For the purposes of this research, no personal data has been extracted. The IP addresses and geographic locations have not been stored in the excel exports as it is not necessary for the purpose of the research. A unique post ID identifies each post. The following findings start with an overview of the networks used by the anti-vaccination community. Trends in volume and engagement are outlined in 5.1. In 5.2, clusters of common belief of the anti-vaccination sentiment are categorized and explained. The importance of influence in the anti-vaccination discussion is illustrated 5.3 because it is critical to understand that communication needs require adjustment to each country or region, which itself can present a challenge. 5.1 Networks: Volume and Engagement During May to July 2012, the researchers recorded messages with anti-vaccination sentiment from 22,349 participants. The majority of participants spoke English, followed by Polish, Russian and Romanian. EMPIRICALFINDINGS Page 15 Figure 2: Participants of anti-vaccination discussions per language. Across all four researched languages, blogs are the most frequently used channel for posting anti-vaccination content in social media. Blog is short for weblog, which is a website normally maintained by an individual (or group of individuals) and updated with regular entries. Entries are typically displayed in chronological order and tagged with relevant keywords and phrases. Blog visitors usually have the opportunity comment and share the content on blogs. Blogs are by far the most important channel in terms of volume of posts in Romanian (86% of all posts) and Polish (85% of all posts). In Russian discussions, 65% of all posts are submitted on blogs and in English nearly half of the anti-vaccination content (47%) is posted on blogs. Facebook is the second largest channel in terms of volume of posts. The social network has a share of 25% in English speaking networks, 13% in Polish, 8% in Romanian, and 5% in Russian channels. Facebook allows users to build personal profiles accessible to other users for exchange of personal content and communication via the Facebook. Twitter, which allows users to send brief (<140 character-long) updates, is the second largest channel in Russian-speaking (24% of the total volume) and fourth with 5% in English-speaking anti-vaccination communities. Other channels to consider are News websites and Forums in which users post comments to engage in discussions about specific topics. Since 68% of all participants in the anti-vaccination discussions during the observed time-period speak English, the dataset is able to reveal more accurate insights into demographics compared to the other languages. Insights in all languages can be found in Appendix 4, while the following analysis focuses on the English Page 16 data set. The English dataset also reveals that blogs have generally the highest rates of mentions (61%), conversations (67%), posts (67%) and interactions (43%). Based on the volume of posts, it is a logical consequence that most engagement takes place on blogs. Engagement is defined as followed: Post: An initial message submitted to a social networking site, i.e. a blog post, Facebook status, tweet, video, etc. Interaction: Any activity created as a direct response to an initial post, i.e. comments, likes, retweets, @replies, etc. Conversation: The sum of a post and all its related interactions. Note: a post with at least one interaction is considered as conversation. Mention: An appearance of search terms in a public social media space. Figure 3: Distribution by channel for Romanian, Russian, English and Polish networks Page 17 Blogs, forums, and Facebook are the leading networks for anti-vaccination discussions in English during the observed time-period. In other words, the anti-vaccination sentiments are expressed on those platforms through posting user-generated content. However, while conversations on forums only makeup 2% of total conversations, they account for 25% of all interactions among users. This indicates a heavily engaged audience. It can Figure 4: Mentions, Conversations, Posts and Interactions per channel. Page 18 be argued that opinions are formed during interactions among users and therefore, it is vital to add pro-vaccination content to the discussions on forums. Similarly, Facebook only contains 9% of conversations, but 21% of interactions. Both channels are important to consider for interactions with the anti-vaccination sentiment even if more posts occur on blogs. Similar findings occur in Forums. Forums are designed to be interactive conversation, where topics are discussed in greater depth. The English dataset is a reflection of this distinguish feature 16% of all posts and 25% of all interaction occur on Forums. The figures show that while the volume of content on Forums is relatively low, the engagement is an important strength that shaped the opinion in the anti-vaccination community. Figure 5 indicates that the data skews towards female audiences when issues such as developmental disabilities (59%), chemicals and toxins (56%) and side effects (54%) are discussed within the anti-vaccination sentiment, whereas men focus on arguments around conspiracy theory (63%) and religious/ethical beliefs (58%). Anti-vaccination social media participants are approximately 56% female and 44% male. Figure 5: Gender comparison in English per argument. Page 19 5.2 Common Arguments The amount of argument-mentions in anti-vaccination sentiment changes significantly by language during the observed time-period. Figure 6 illustrates that conspiracy theory and religious/ethical beliefs are the main topic trends in English, while religious/ethical beliefs drive the majority of discussions in Russian speaking anti-vaccination discussions. Polish anti-vaccination discussions are driven by arguments about side effects and chemicals and toxins in vaccines. The issue of chemicals and toxins is the major driver in Romanian discussions during the observed time-period. The arguments are described in detail in the following sections. The categories are based on keyword strings that were narrowed down over time. Issues should not be regarded in a static way, they might overlap and are interconnected. 5.2.1 Religious and Ethical Beliefs Religious and ethical discussions are especially active in discussion in Russian, with 96% of all anti-vaccination discussions focused on that issue. In English discussions, 32% of all anti-vaccination discussion use religious and ethical arguments. The arguments are less relevant in Polish (5%) and Romanian (0%) speaking anti-vaccination discussions. The main train of thought derives from Figure 6: Allocation of arguments by language for the anti-vaccination sentiment. Page 20 the belief that humans are created just as they should be and external interference is not required. My body was designed by God to be self healing and self regulating and no man will be able to do better than God is a quote by a female blog commentator from the US. Another user states, anything that involves substances that should never belong in a humans body, should not be injected or consumed without that individuals consent. Anti-vaccination advocates believe in homeopathy and alternative medicine. My BodyMy Decision writes a community member from Australia. A broad sentiment that mandatory vaccination is a violation of human rights can also be detected. From an ethical standpoint, the anti-vaccination community claims that it is a basic human right to be free from unwanted medical interventions, like vaccine injections. The same kind of argumentation can be recorded in all four languages. On June 15th 2012, the Polish Parliament voted to change the existing laws on vaccinations. The Act on Preventing and Fighting Infections and Infectious Diseases in Humans and in The Act on National Sanitary Inspection has created controversy among social media users because of it makes vaccination mandatory. The anti-vaccination advocates were sending petitions to the Polish President demanding him to stop the act. The petition received support from some representatives of the Catholic Church, but not an official support from the church as whole. Radio Maryja, the most powerful independent catholic media in the country, also critiqued the act based upon: The argument that vaccines are made based on cell lines derived from the bodies of babies killed by abortion. The notion of unethical activities by campaigning teenagers and women to be vaccinated against HPV infection and it is promoting immoral, and disorderly behaviour in the area of sexuality. 5.2.2 Safety and efficacy Side effects are the most common anti-vaccination theme in Polish networks (28%), but they also play a role in English networks (9%) and Romanian (5%). The argument is mentioned in less than 1% of all anti-vaccination discussions in Russian language. Typically, parents who reach out to online communities because they are unsure about vaccines trigger the discussions about side effects. Individual stories from parents are powerful because they humanize the discussion. One user writes, My baby is 5 months old, not vaccinated and he is going through pertussis right now! Its very scary! I HATE it! I have 3 children, the other 2 were vaccinated but Im scared to vaccinate my baby! Any other mommys new at Page 21 this? This quote reflects a level of fear and uncertainty about the right thing to do, even though the mother has experienced both the effect of vaccines and vaccine-preventable diseases. Another parent writes: My brother, sister in law, and all three kids under the age 5 were vaccinated for whooping cough and they all got it! An argument in a Russian network claims that live vaccines can mutate in the organism and create deadly strains. The fear of side effects leads to discussion about vaccines causing diseases and death. A user from the UK argues, The only way you can get this virus is if it is injected into you. Besides individual stories, argumentation backed by figures without context or sources are equally powerful in fostering fear of vaccines. For example, a member in one English network posts: Vaccinated children have up to 500% more diseases than unvaccinated children. Community members in Russia postulate that vaccinated children get sick 2-5 times more often than non-vaccinated children. For example in Romania, school nurses perform the mandatory vaccination during class, which is seen as a human rights violation and a safety issue. Parents are sceptical about the skills of the school nurses and feel surpassed by authorities in its decision to have children vaccinated. A user in a Polish anti-vaccination community states: I am a mother of two disabled children. When my daughter was five months old, she had a negative reaction to the vaccine, now she has been diagnosed with autism and mental retardation. For 10 years, I did not vaccinate my children and I would not want the right to decide on this matter taken away from me. I am an educated person, and have researched the subject and do not believe in the efficacy or safety of vaccinations. 5.2.3 Developmental Disabilities Another reoccurring argument in the anti-vaccination sentiment claims that vaccines contain toxins and harmful ingredients. Injecting vaccines into the body of a child leads to brain injury and developmental disabilities. This theme is discussed in 15% of all English and Polish speaking anti-vaccination discussions. Development Disabilities was in less than 1% of anti-vaccination discussions mentioned in Russian or Romanian networks. The arguments evolve from sentiment surrounding vaccines posing challenges to the immune system and producing antibodies that may cause autoimmune diseases. Another notable argument is that vaccines are not able to fight off the mutant viruses that develop over time. Across communities, anti-vaccination advocates link vaccines to Page 22 epilepsy, autism and neurodegenerative diseases (Parkinson and Alzheimer). A member of the Polish community writes: Mercury causes developmental disorders in children (including epilepsy and autism), in adults, neurodegenerative diseases (Parkinsons and Alzheimers), and degenerative changes in the reproductive systems of men and women, impairing their ability to reproduce offspring. It is notable that figures are used based on estimates by the author without links to sources. A Russian speaking user notes that vaccinations against pandemic influenza H1N1, also known as swine, can lead to the development of Guillain-Barr syndrome, acute poliradikulita in adults, according to Canadian researchers, published in the journal JAMA. 5.2.4 Chemicals, Toxins and Unnecessary(administration of vaccines) Our doctor has advised us to avoid vaccines in absence of a direct disease risk, since the long-term side effects have not been studied writes a member of an English-speaking community. One common argument recorded in the anti-vaccination sentiment is that studies about risks and impact of vaccinations are insufficient. Vaccines have not been tested enough and have concerns regarding the lack of long-term side effects studies. Another user states that I would really want to know whether and how well vaccine manufacturers test their final vaccine products () and how much contamination they discover. A common belief is that children having a vaccine-preventable illness just need food, water, and sanitation. In Polish communities, members use the example of Scandinavian countries lobbying for a ban of questionable and potentially harmful ingredients in vaccines. The notion that Scandinavian countries banned Thimerosal a long time ago and they have a much lower percentage of children with autism was classified was an important argument for users. Drawing on that example, the most common belief in Polish communities is that mercury may cause autism. A Russian-speaking user concludes, a recent large study confirms the results of other independent observations, which compared vaccinated and unvaccinated children. They all show that vaccinated children suffer 2 to 5 times more often than non-vaccinated children. Sources or links to the recited studies are not provided. 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest In English-speaking anti-vaccination communities (24%), a strong distrust against governments and pharmaceutical industry is Page 23 recorded. The same applies for Polish (5%), Russian (1%) and Romanian (3%) at a smaller scale. However, the U.S. and western governments are viewed critically when discussing about governments and conflict of interest. In Polish networks excessive vaccinations are seen as promoted by pharmaceutical companies in order to gain profits. The role of the pharmaceutical industry is discussed mostly negatively. The sector is regarded as corrupt marketing machine. An English-speaking user states that: In the vaccine industry, scientific fraud and conflicts of interests are causing a similar cycle of deaths and injuries that is being concealed and denied by regulators and vaccine manufacturers. The industry is viewed as profit-driven and has moved from its original purpose to save lives and protect humans. Romanian discussions directly blame the U.S. for purposefully infecting people with HIV using polio vaccines. Users create a direct link between vaccines and widespread HIV in Romanian orphanages. In the same sense, users claim that vaccines are being used against the Romanian populations. According to members of the anti-vaccination sentiment, vaccines against polio and chickenpox are used in Romania, which are not used in the U.S. anymore. Polish anti-vaccination communities state the examples of swine flu and bird flu two years ago. According to the users, both cases are plots by giant pharmaceutical companies. Some countries desperately bought a huge quantity of vaccines, while Poland acted rationally and did not buy the vaccines, which saved the state budget a couple of billion. The activists are suspicious because the epidemic ended after the new vaccines were purchased by several governments. The distrust against governments is also reflected in conspiracy theories. Patterns in English-speaking communities suggest that immunization is used to control and reduce the world population. One strain of argumentation is that vaccines that are not allowed in developed countries are imported to developing countries in order to reduce population growth. 5.3 Influencers Opinion leaders in anti-vaccination sentiment show varying characteristics across countries. However, they often appear to be well educated in alternative medicine. Some have no college education; others are in the medical field (such as nurses). A high level of volume and interaction can be recorded for influencers. They often subscribe to social channels of homeopaths and Page 24 alternative medicine advocates but they can be found across platforms. The following section lists a range of influencers that are active in different channels or languages: Name Position Facebook Fans Twitter Followers Blog Language Dr. Tennpen-ny The Voice of Reason about Vaccines 36,282 1,475 Yes English The Truth About Vac-cines Answering questions from concerned parents 21,246 N/A Yes English International Medical Council on Vaccination Purpose is to counter the messages asserted by pharmaceutical com-panies, the government and medical agencies that vaccines are safe, effective and harmless 7,983 N/A Yes English The Refusers "Vaccination choice is a fundamental human right." 9,069 12,457 Yes English Mothering Magazine Mothering is the pre-mier community for naturally minded par-ents. 66,504 102,173 Yes English Oglnopo-lskie Sto-warzyszenie Wiedzy o Szczepieniach STOP NOP Protest against new laws for mandatory vaccinations in Poland and against disinforma-tion campaigns about the effectiveness and safety of vaccines. 3,203 N/A Yes Polish STOP Pr-zymusowi Szczepie Petition campaign against new new laws for mandatory vaccina-tions in Poland. 2,866 58 Yes Polish Table 1: Examples of influencers in the anti-vaccination sentiment in social media. Page 25 With respect to the above-mentioned arguments, opinion leaders in the anti-vaccination movement put an emphasis on highlighting negative stories that focus on individual cases. In some cases, they blame outbreaks on shedding vaccinated children who get unvaccinated children sick. The argumentation is based on the conviction that vaccines are unsafe and dont work. A list of common arguments by arguments by influencers per language can be obtained in Appendix B. In this section the research question will be discussed in light of the theoretical and empirical findings. It needs to be noted that the discussion only focuses on engagement with anti-vaccination advocates in the four researched languages. This does not include pro-vaccination movements, medical professionals, partners or others. The discussion will propose a model that illustrates the different drivers of anti-vaccination sentiment based on three elements. The recommendations section builds on the three elements of the model and provides practical advice for communication strategies. 6.1 Discussion In order to develop engagement and messaging strategies for anti-vaccination sentiment, it is vital to have an abstract understanding of what drives users to become suspicious about vaccinations. Based on the findings, the paper proposes a model of anti-vaccination sentiment identification and salience. We classify three main spheres that attribute to a negative sentiment towards vaccine, which help us in the identification of trends within the anti-vaccination sentiment. The classification is illustrated in the following figure: DISCUSSION &RECOMMENDATIONS Page 26 The first attribute is the individual sphere. The main motivations for users to get involved are highly personal matters driven by concern and fear. When it comes to vaccinations, some parents are not sure what the right decision is. Am I a good mother if I do not get my child vaccinated or is it my responsibility as a caring parent to ensure the best protection for my child? Personal testimonies of other parents, especially negative stories, have a huge impact on the parent and fuel the concern. The second element that characterizes the anti-vaccination sentiment is the contextual sphere. The main driver behind the contextual sphere is a distrust of governments, pharmaceutical industry, scientific bodies and international organizations. It seems to be overwhelming for parents to understand the role of the big players. An interesting observation is that users in the contextual sphere do not seem to have a general resentment against vaccines per se but most arguments focus on lack of transparency in the decision processes as well as the potential conflict of interests trigger distrust. The third attribute is labeled as transcendental sphere. Negative attitudes towards vaccinations are derived from idealistic, religious and ethical beliefs. Arguments are rooted in strong beliefs and appear dogmatic, such as God creates us in the most ideal way or a body has its natural balance. Figure 7: Model of anti-vaccination sentiment identification and salience. Page 27 Individual, contextual and transcendental sphere are the key attributes of a member of the anti-vaccination movement. We argue that the various combinations of these attributes are indicators of the salience of members. We can identify four groups that derive from Figure 3. In order to understand salience within anti-vaccination community members, we propose the following classification Core Members are users that apply to all three spheres. They are concerned about side effects, distrust the government and live according to strong religious or ethical beliefs. Intense Members are members that apply to two of the three spheres. For example, a user might have concerns about vaccinations based on an individual sphere and also carry distrust against the pharmaceutical industry. But they are not driven by any idealistic beliefs. Alert Members are users that apply only to one of the three spheres. The doubt about vaccines derives only from one sphere and has human characteristics. They seem to be less convinced of the harm of vaccinations than the other two member groups. There is a fourth group of users, the Non-Members. They simply do not apply to any of the classification. We argue that Alert Members are easier to convince of the necessity of vaccines than Intense Members. Core Members are the hardest to convince, because the arguments against vaccines are based on various foundations. The findings also show that the intensity of argumentation, the interaction and the volume varies between the spheres. Therefore, the next section outlines practical recommendation on how to draft engagement strategies for each sphere. 6.2 Recommendations The following graphic summarizes the framework for the engagement and messaging plan that enables communication officers and health workers to react to the anti-vaccination sentiments. The framework is designed to be customizable for local realities. However, it does provide an overarching guidance for communication and campaigning initiatives. Members of the individual sphere should be approached with an emotional appeal. Users in this sphere go online and search for information in order to make an informed decision. Content that encourages parents to get their children vaccinated needs to be easy to find. Hence, search engine optimization plays an important role in the outreach strategy. Search marketing is used to gain visibility on search engines when users search for terms that relate to immunization. In order to appear on top if the search Page 28 results two general approaches should be considers: Organic search (SEO): When you immunization or vaccines into a search engine like Google or Yahoo!, vthe organic results are displayed in the main space of the results-page. For example, when parents search for information about vaccinations, pro-vaccine information should rank on top of the search engine results. By optimizing websites and posts, organizations and governments can improve the ranking for important search terms and phrases (keywords). Engaging actively in discussion and providing links to pro-vaccination content also helps to increase the visibility in the ranking. Paid search (SEM) enables to buy space in the sponsored area of a search engine. There are a variety of paid search programs, but the most common is called pay-per-click (PPC), meaning the information provider only pays for a listing when a user clicks the ad. The emphasis of the content strategy is to empower parents to ask doctors the right question in order to build confidence for the decision making process. Rather than criticising parents choices not to vaccinate, the messaging should promote an individuals ability to make the world a safer place for children. The communication strategy should also highlight the individual right and responsibility to choose to vaccinate. Through emotional Figure 8: Engagement Matrix for core spheres of the anti-vaccination movement. Page 29 messaging, hesitating parents should receive key information and explain how their choices affect their own children and the ones of others. The communities in the contextual sphere source their scepticism from general distrust against the large players involved in the vaccination industry. The engagement strategy should be based on a rational appeal that focuses on the hard facts of vaccines. It is important to avoid obvious communication tactics. Transparency about vaccines, testing, ingredients, potential side effects, funding and preventable diseases is crucial to reduce distrust. The messaging should also take into account past errors in vaccine campaigns by governments and suppliers in the regions and most importantly focus on the lessons learnt and how processes have been improving since then. Transparency can be built through a multi-channel approach that features the development of vaccines with expert testimonies. Successful cases, such as the near eradication of polio as a global effort, help to reduce distrust as well. This can be backed by official statistics on how infant mortality rates have been reduced over the past 20 years. Countries that generally have a favourable public perception, such as Scandinavian countries,

Basis for a European Child Guarantee Action Plan in Lithuania PH OTO : DA NIJ EL SO LDO iBasis for a European Child Guarantee Action Plan in Lithuania When citing this report, please use the following wording: UNICEF, Basis for a European Child Guarantee Action Plan in Lithuania, UNICEF Europe and Central Asia Regional Office (ECARO), 2022. Authors: This policy brief has been prepared by a team led by Alina Makareviien, Project Manager and Lead Expert at PPMI. Haroldas Broaitis, PPMI Research Director, contributed to the report as a scientific advisor. The following experts have provided content on their areas of expertise: Greta Skubiejt (early childhood education and care and education), Agn Zakaraviit (health and housing), Aist Vaitkeviit (nutrition, material child poverty and social exclusion), Loes van der Graaf (administrative coordinator). Project management: Daniel Molinuevo, together with Kristina Stepanova (European Child Guarantee National Coordinator in Lithuania) and the rest of the Steering Committee of the third preparatory phase of the European Child Guarantee in Lithuania. Acknowledgements: Thanks are also due to James Nixon, language editor at PPMI, and many other experts who have shared their knowledge. UNICEF, 2022 The information and views set out are those of the authors and do not necessarily reflect the official opinion of the European Commission and the Commission cannot be held responsible for any use which may be made of the information contained therein. More information on the European Union is available at www.europa.eu. The material in this policy brief was commissioned by UNICEF ECARO in collaboration with the Lithuanian National Committee for UNICEF. UNICEF accepts no responsibility for errors. The findings, interpretations, opinions and views expressed in this publication are those of the authors and do not necessarily reflect the policies or views of UNICEF. Contents 1. Introduction 01 2. Free and effective access to ECEC 03 3. Free and effective access to education 07 4. Free and effective access to health care 11 5. Effective access to healthy nutrition 15 6. Effective accesss to adequate housing 18 7. Social services and benefits in cash 21 iiBasis for a European Child Guarantee Action Plan in Lithuania PH OTO CR ED IT: U NIC EF, SA MIR KA RA HO DA 1. Introduction Child poverty has an immediate and long-term effects on both individuals and society. Due to particular needs of children, and the limited coping capabilities tied to their specific life stage, children are impacted more acutely by poverty, particularly at an early age. Poverty and deprivation during childhood impact an individuals health, educational attainment, employability and social connections, and increase the risk of future behavioural problems. Thus, poverty and social exclusion at a young age often extend into later stages of life, perpetuating intergenerational poverty and inequalities. Childrens experiences of poverty and social exclusion depend not only on the extent of income poverty and material deprivation, but are also highly influenced by their immediate caregiving environment (e.g., family composition, foster care) and the characteristics of the local community (e.g. the level of access to public services). This policy brief contributes to the drafting of the Lithuanian National Action Plan on reducing child poverty and identifies the key challenges to achieving the goals of the European Child Guarantee in Lithuania. It provides an overview of the policies currently in place and provides recommendations ranging from improving access to free early childhood education and care (ECEC), to education, health care, healthy nutrition, , and adequate housing. This policy brief is based on the findings and recommendations identified in the deep-dive analysis and consists of five parts, each covering a different policy area. Each part comprises three sections, dealing with the main access barriers to access, policy responses and recommendations for ECEC, education, health care, nutrition and housing services for children. 1 2Basis for a European Child Guarantee Action Plan in Lithuania Key messages Effective access to quality ECEC services is one of the most important factors in ensuring equality in childrens further development and academic achievements, as well as to ensuring childrens safety. Meanwhile, in Lithuania, access to ECEC remains one of the biggest challenges especially for the youngest children. Not enough places are available in public centres, and private for-profit services are very expensive. In addition, hidden costs (such as meals and transport) exist even in the public sector, thereby rendering access to ECEC especially problematic for the most vulnerable children, such as children from low-income families and families at social risk. Due to the large group sizes in public ECEC centres and a lack of learning support specialists, there is also a lack of inclusion with regard to children with SEN (Special Education Needs), disabilities, and children from minority groups. Effective access to education, first and foremost, requires equality among schools and regions within the country, which is currently lacking in Lithuania. Vulnerable children, such as children from low-income families, children from families at social risk, children in rural areas, and children from national minorities within Lithuania, receive a lower quality of education. The reason for this is that schools in rural areas and in certain parts of cities, as well as schools for national minorities, lack qualified teachers, necessary learning equipment, up-to-date books and methodologies. The issue of hidden costs also applies, particularly in relation to access to non-formal education. Meanwhile, children with SEN and disabilities do not receive quality education due to teachers lack of knowledge about working with such children, as well as a lack of adapted methodology, and a lack of learning support specialists. To reduce these barriers, all schools should be equipped with laboratories, IT equipment, highly qualified teachers, all necessary learning support specialists, up-to-date books, and adapted methodologies. Schools should also provide children with universal benefits and represent cultural diversity. Meanwhile, with regard to non-formal education, children must be provided with a wide range of activities that correspond to their individual needs and capacities, and transport should be provided for children with SEN and disabilities as well as children living in distant areas. Socio-economic disadvantages negatively influence childrens access to the healthcare system in Lithuania due to families inability to afford treatments, long waiting lists, long travel times or no means of transport, a lack of time due to parents working commitments, etc. Effective access to free healthcare requires improved access to healthcare services for the most disadvantaged groups such as children in low-income families and precarious family situations; a greater focus on children with disabilities and special needs, as well as Roma and migrant children; the development of mental health services and the improvement of after-school opportunities for childrens physical activity. A lack of effective access to healthy nutrition during infancy contributes to a range of poor health outcomes in future life, as well as impacting physical and mental well-being and cognitive functioning, and contributing to lower learning outcomes. The most vulnerable children in Lithuania are those from low-income families, families at social risk, and children living in remote rural areas. Parents with low incomes cannot afford healthy foods as these are often more expensive than less healthy alternatives. In addition, parents at social risk may lack knowledge regarding the importance of nutrition, and parents raising children in remote areas may face additional barriers of access due to a lack of transport or its cost. The most vulnerable period for children is during infancy, when they should be breastfed, and their nutrition relies on mothers awareness as well as their eating habits. Tackling barriers to access such as the affordability of healthy foods, as well as addressing unhealthy eating habits by promoting and enabling healthy eating and ensuring that all children have at least one full healthy, balanced meal per day, are therefore particularly important in tackling food insecurity for AROPE children. Housing deprivation is a much bigger issue for children living in low-income families compared with other income groups of children in Lithuania. Effective access must be ensured to adequate housing and access to housing support services needs to be improved for the most disadvantaged groups in Lithuania: children in low-income households, children of single parents, children from large families, children with disabilities, Roma and migrant children. A greater focus should be placed on improving the income situation of families in Lithuania. Social services and benefits in cash significantly improve access to ECEC, education, health care, nutrition and housing. In Lithuania, some of these benefits include universal child benefits, social benefits, the family card, and one-time COVID-19 benefit and benefits for pregnant women. Other important programmes to improve the overall situation of the most vulnerable children include the action plan for complex services for families, the child well-being programme, case management and the policy of deinstitutionalization. 3Basis for a European Child Guarantee Action Plan in LithuaniaP HO TO C RE DIT : UN ICE F 2. Free and effective access to ECEC Main challenges experienced by children regarding ECEC in LithuaniaAccess to ECEC services remains a challenge in Lithuania. As in most post-Soviet countries where policies have been shaped to support stay-at-home mothering and nuclear families, and where a clear division of gender roles exists between men and women, insufficient attention has been paid to expanding the ECEC system. Policy in Lithuania has traditionally focused on supporting the aforementioned gender roles, and inattention towards developing the ECEC system has led to a lack of available ECEC services and a lack of flexibility in those services that do exist (both in terms of working hours and the types of ECEC providers), particularly with regard to children aged 0 to 3 years old. In addition, there is insufficient inclusion and access to ECEC services for children with Special Educational Needs (SEN) and disabilities, children with migrant backgrounds and children living in families at social risk, especially when such children live in rural areas. Due to a lack of public services, parents have to rely on private for-profit services, which are very expensive. Most vulnerable families, such as single-parent families, cannot afford them. For single-parent families, the situation is extremely complicated: they may face long waiting lists for enrolment into ECEC, as most municipalities in Lithuania give priority in enrolment into ECEC to families in which both parents are registered in the same area. On top of this, even in public ECEC centres, hidden costs constitute a great burden for low-income families. Meanwhile, in many cases, families with children living in rural areas cannot afford transport to and from ECEC services. Inequality between children in the education system is therefore present from a very early age. 3 4Basis for a European Child Guarantee Action Plan in Lithuania Table 1 . Number of children requiring free and effective access to ecec Vulnerable group Estimated size of the group Data source and year Children in low-income families 21.6% (38, 000) of children up to 6 years old are at risk of poverty Eurostat, 2020 Children living in families at social risk 17,430 (children of all ages) Official Statistics Portal, 2018 Children living in rural areas 50,232 Education Management Information System, 2020-2021 Children with special needs and disabilities 24,962 Education Management Information System, 2020-2021 Children with migrant backgrounds Returnee children: 976Immigrant children: 1,007 Ministry of Education and Science, 2018Official Statistics Portal, 2020 The policy responses to improve access to ECEC To improve the availability of ECEC services, the Lithuanian government has established mandatory pre-primary education. Other tools include recognizing different forms of ECEC provision, providing children with transport, free meals and more. The National Education Development Programme 2021-2030 foresees that by 2030, 95% of children between ages of 3 and the age of compulsory primary education will attend ECEC services, while 75% of children from families at social risk will attend ECEC. It is also foreseen to improve the inclusion of children with SEN. The main tools to achieve these goals include the creation of new ECEC sites (including modular kindergartens and family kindergartens), and the improvement of teachers competences via various courses and peer learning. Modular system kindergartens are flexible spaces, generally made from light construction modules, which can be easily remodelled if necessary. Family kindergartens, meanwhile, are formed when a child-raising parent takes care of other children for a certain fee, using the facilities of his or her own home. Nevertheless, while the goals of current policies are promising, there is a lack of concrete steps that need to be taken, together with a lack of financial distribution. In the current situation, access to ECEC among the most vulnerable children remains a challenge, as priorities regarding enrolment into ECEC remain based on the strengths of families, rather than their vulnerabilities, such as raising children alone, and there is a lack of transport, learning support specialists and other resources. The Description of the Requirements for Teachers qualifications foresees that at least one teacher in the childrens group should have a BA qualification; all teachers should have attended courses of at least 40 hours on working with children with SEN, disabilities, and other vulnerable backgrounds, and at least 40 hours of courses on teaching the Lithuanian language. Nevertheless, there is still a shortage of workforce in ECEC due to the professions lack of attractiveness and the lack of financing in this area. Although salaries for pre-primary teachers have been raised, ECEC teachers and learning support specialists remain among the lowest-paid professionals. To help ensure the quality of services, all ECEC centres are also provided with methodological recommendations. These recommendations include topics such as identifying childrens individual needs and improving childrens academic, artistic and social skills. Moreover, they provide information on how to approach and work with children with SEN, disabilities, migrant backgrounds, as well as children from low-income families and other vulnerable backgrounds. Meanwhile, mandatory pre-primary education for all children, and mandatory ECEC education for children from families at social risk, as well as a minimum of 5 hours mandatory provision of Lithuanian language courses for migrant children of all ages while attending ECEC, seek 5Basis for a European Child Guarantee Action Plan in Lithuania to ensure childrens safety and equality. The aim of these measures is to provide children with an equal starting point when they attend primary school; however, such measures are not always carried out due to a shortage of workforce and the competences of teachers, as well as the large sizes of childrens groups. Other tools include the provision of transport, increasing the number of ECEC centres, and assessment tools for children. In addition, children from families at social risk are also provided with free meals, learning equipment, family monitoring by The Child Welfare Commission, and counselling parents regarding the benefits of ECEC. Recommendations for improving access to ECEC Make ECEC universal for children from 0 years old to the age of compulsory primary education, with priority being given to children from disadvantaged backgrounds. The current goal is to achieve universal ECEC for all children between the ages of 2 and primary education by 2025. Progressive universalism could help to reach these goals. Progressive universalism means that children from vulnerable backgrounds are given priority in terms of access to ECEC. Financial allocations could also be raised to help children from vulnerable backgrounds to access ECEC. More attention to parents and their needs. It is important to inform parents about the benefits of ECEC via families social workers and health care specialists. Outreach mechanisms could provide significant benefits in terms of involving children from vulnerable backgrounds. It is also crucial to help parents with bureaucratic processes, and to simplify these processes as much as possible. Improve the inclusion of children with SEN. Although quality ECEC has a dramatic impact on the development of children with SEN, currently only around 20% of such children attend general ECEC in Lithuania. Improving the inclusion of children with SEN requires extended training for the ECEC workforce, both during their initial studies and while working in ECEC. There is currently a lack of teacher training in this area, mainly due to a lack of financing. This should be improved. In addition, it is important to reduce the sizes of childrens groups, and to determine the number of children per teacher. Where teachers work with groups including children with SEN, those groups should contain a smaller number of children. Address issues of gender inequality and reconciliation of work and family life. ECEC services are important for removing obstacles to the employment of women, particularly single mothers, and for single parents in general. Access to ECEC contributes to gender equality by allowing greater flexibility to manage family and work-life balance for both mothers and fathers. It is important that more flexible ECEC services are made available, with different working hours, and that single parents are given priority with regard to enrolment in ECEC. Address geographical disparities. Lithuania is currently unable to ensure equal enrolment into ECEC across the country. First and foremost, increasing access to ECEC, means developing infrastructure and increasing the number of teachers. The level of provision is lower in rural areas than in urban areas, and in urban areas, fewer high-quality ECEC resources are available in poorer neighbourhoods. Clear guidelines regarding structural quality and financing must be set at national level, to avoid children suffering inequalities in conditions depending on where they are born. It is also necessary to ensure equality among ECEC providers regarding the quality of services provided to children with SEN and disabilities, and to ensure that these children receive high-quality services close to their homes. Support the ECEC workforce. As previously mentioned, more time and money should be invested into the continuous professional development of working teachers as well as teachers training. The strong connections with teacher training institutions for ECEC could be further expanded to include on-site training or mentoring for working teachers. Moreover, professional development should be embedded into the process of quality monitoring, creating a system that focuses on measuring quality, reflecting on the results, and supporting teachers in making improvements. Every teacher should receive continuous professional development training continuous training and supervision in class, as well as training on special education, psychology, and IT; teachers should be able to attend qualification courses abroad and to receive video 6Basis for a European Child Guarantee Action Plan in Lithuania feedback. More attention should be focused on improving teachers salaries and the status of the teaching profession, as well as increasing diversity among teachers in ECEC centres. Set clear requirements for curriculum. Curricula need to be planned within an open framework that acknowledges and addresses the diverse interests and needs of children holistically. This should include addressing differences between boys and girls; children with SEN; children from national minorities; and children from families at social risk. While planning curricula, it is important to take into account global challenges, technological advancement, topics relating to everyday life challenges, and the identities of various ethnic minorities. Children, especially those from families at social risk, should be provided with facilities to meet their hygiene requirements, and centres should pay extra attention to the nutrition and health of such children. With regard to children with SEN and disabilities, recommendations provided by doctors and other services should be followed carefully at all times. It is also important to involve children and their parents in the process of creating curricula. Ensure that policy goals are oriented towards improving access to and the quality of ECEC. Strong public policy commitment to ECEC is important, and must be backed by a bold vision, strong plans and adequate funds. Promoting ECEC as a central priority in national education strategies and plans including clear targets, indicators and ministerial leadership can make a significant difference in terms of the political and financial importance given to the sector. Robust governance and accountability mechanisms across decentralized levels are also important in ensuring the efficient allocation and use of ECEC resources. Develop comprehensive quality monitoring. To ensure success, the monitoring and assessment framework should cover structural aspects of quality (child-staff ratio, qualification levels of staff); process quality (e.g., interaction with children, the content of activities); and outcome quality (looking at the benefits for children, families, communities and society). Monitoring needs to include assessments of the accessibility of ECEC for children living in rural areas, children from low-income and single parent families, for families at social risk, and for children from ethnically non-Lithuanian families. Furthermore, the quality of staff, price of services, curricula, governance and funding should also be monitored. General quality criteria need to be set at the highest possible levels, but should also encompass regional and local levels, and should ideally align with the EU ECEC Quality Framework. The ECEC workforce, the children themselves and their parents should all be empowered and included into the quality monitoring process. Information from both self-assessment and external evaluations regarding the quality of the ECEC system should be used as the basis for improvement. Information about the quality of the ECEC system should also be made available to the public. PH OTO CR ED IT: U NIC EF 3. Free and effective access to education Main challenges experienced by children in Lithuania in relation to education Although education is free and universal for all children in Lithuania, many barriers to access and other challenges still remain. First and foremost, great inequality exists between schools in terms of the quality of services, with the greatest disadvantage evident in schools in rural areas, certain areas of cities and in minority language schools. Such inequality exposes children living in rural areas and less well-off urban areas, as well as the children of non-Lithuanian ethnic groups, to low-quality education. Many of the schools attended by these children suffer a lack of laboratories, IT equipment, learning support specialists, up-to-date books and methodologies and highly qualified teachers, and a lack of transport to and from non-formal education activities as well as a lack of choice in such activities. The lack of learning support specialists and lack of choice in free-of-charge non-formal education activities, especially among children with SEN and disabilities, is major and prevent problem in all schools. Moreover, although education is considered free of charge for all children, hidden costs remain a great issue. Despite school tuition being free, the families of school students have to pay for certain school materials, activity books, transport, food and various extra courses and activities that contribute to their learning. This can be extremely problematic for low-income families, especially those living in remote areas, where hidden costs limit access to both formal and non-formal education. Immigrant children, returnee children and children of migrant origin are also insufficiently included in the educational system. There is a lack of teachers from different cultural backgrounds in schools, Lithuanian language is not sufficiently well taught to non-native-speaking children, and teachers lack the skills to work with children with different languages and cultures. A lack of learning support specialists is also a major problem in this context. 7 8Basis for a European Child Guarantee Action Plan in Lithuania Table 2. Number of children in need of free and effective access to education Vulnerable group Estimated size of the group Data source and year Children in low-income families 24.8% (100, 000) of children between ages of 6 and 19 are at risk of poverty Eurostat, 2020 Roma children 1,036 (children of all ages) Overview of Roma situation in Lithuania, 2016 Migrant and returnee children Returnee-children: 412 Immigrant children: 3,303 Ministry of Education and Science, 2018OSP, 2020 Children from non-Lithuanian ethnic backgrounds 31,502 Education management information system, 2020-2021 Children living in rural areas 53,510 Education management information system, 2020-2021 Children with special needs and disabilities 4,873 Education management information system, 2020-2021 Policy responses to improve access to educationThe Lithuanian government recognizes the issue of low academic achievements among Lithuanian children and its link to the lack of quality of education in Lithuanian. The government recognizes issues such as inequalities between schools and the lack of inclusion of the most vulnerable children such as children with SEN and disabilities and children of migrant origin. To reduce these inequalities, it proposes to equip all schools equally with highly qualified teachers, learning support specialists, laboratories, IT equipment and the necessary methodologies. The National Education Development Programme 2021-2030 foresees that by 2030, 97% of children with SEN and 75% of children with disabilities will attend general education schools; 75% of all children will attend non-formal education; 50% of children with SEN will attend non-formal education; 65% of teachers will be employed in schools after graduation; and 40% of teachers will have MA degree. In addition, it is expected to improve pupils PISA results to reach 16th place among all participating countries by the year 2025. To achieve these goals, the government has allocated a budget of EUR 550 million. The Strategic Action Plan of the Ministry of Education, Science and Sport for the year 2021-2023 seeks to improve teachers qualifications; implement the monitoring and assessment of students, schools and education as a whole; develop infrastructure for inclusive education; and to integrate formal and non-formal education. Tools to achieve these goals include courses to improve teachers competencies; increases in teachers salaries; online self-assessment programmes for schools; monitoring indicators for education; purchasing additional school buses and laboratory equipment; modernizing school infrastructure; modernizing non-formal education facilities; increasing support to Lithuanian schools abroad; providing coordinated support to immigrated and returnee children and their families; expanding the number of all-day schools; and increasing funding for student benefits. Nevertheless, teaching remains among the lowest-paid professions, and teachers do not receive any of the financial and educational support necessary to motivate them when working with children with SEN and disabilities, or with children from minority backgrounds. The Political Programme of the XVIII Government of Lithuania also sets similar goals. In addition, it foresees the establishment of national education quality standards and improvements in the quality of education in minority schools. Although most of these goals are similar to those set in previously mentioned documents, the Political Programme of the XVIII Government of Lithuania foresees the use of different tools to achieve these goals. These include modernizing the curricula (including a multilingual reading and maths programme, as well as updated history programmes that recognize the importance of minorities in Lithuanian culture), reduced class 9Basis for a European Child Guarantee Action Plan in Lithuania sizes, additional financing for learning support specialists, more up-to-date books in minority languages, and the digitalization of minority schools. According to data from interviews, the issue of schools lack of autonomy still remains, as they are not given the power to make their own decisions regarding financial allocations and various aspects of curricula, despite the schools themselves being best placed to know what is missing, and what is necessary for their children. Educational tools of the largest scale will include mobile school staff teams and millennial schools. Mobile school staff teams will consist of teams of teachers and other learning specialists that will go to schools facing issues and work there temporarily to improve the situation. Millennial schools will be located in different regions in Lithuania and will benefit from better teachers and STE(A)M laboratories, and modern curricula for formal and non-formal education. All children from the surrounding region will be able to use the facilities and courses provided at these schools. These schools are intended to reduce inequalities between regions, and to provide equal opportunities for all children irrespective of their living place, as well as to improve overall academic achievements. Nevertheless, some of the experts interviewed as part of this research expressed concern that these schools might even worsen equality among regions and children, as millennial schools would absorb all of the best resources in the area and become elite institutions. Children learning in other schools in the area would thereby receive an even lower quality education, as not all of them would have access to these elite schools. The inequalities between schools and regions with regard to quality therefore remains an issue. More detailed, focused tools and more integrated solutions are required to break the cycle of poverty by providing every child with the highest-quality education at all educational levels. Meanwhile, the Law Amending the Law on Education of the Republic of Lithuania and The Description of the Procedures for Organizing the Education for Pupils with SEN, seek to improve the inclusion of children with SEN, those with disabilities and those from other vulnerable backgrounds (migrants, at social risk, from low-income families etc.), as well as to reduce the number of school dropouts. The tools provided include continuously working with childrens parents, pupil self-care plans (provided for children who have various health issues), and individual learning plans. Other tools include the provision of special classes, transport, school meals, school supplies, and improved inter-institutional cooperation. Municipal administrations are encouraged to work more effectively to ensure the well-being of the child, to remove interdepartmental barriers between educational assistance, municipalities, state institutions and establishments, organizations and non-governmental actors, to ensure inter-institutional co-operation. Improved inter-institutional attention to vulnerable children and their parents should reduce social exclusion, dropouts from schools, as well as improve parents skills and involvement in their childrens education, in addition to improving childrens psycho-emotional well-being while attending educational institutions. Inter-institutional co-operation means that all of a childs needs must be identified and dealt with through cooperation between all of the necessary services and support providers. Nevertheless, the inclusion of children with SEN and disabilities, in general, remains a great challenge due to the aforementioned lack of competencies and motivation among teachers, as well as a lack of learning support specialists and the physical appropriateness of schools buildings. Other smaller-scale programmes also exist, such as quality baskets, all-day schools, day care centres and financial baskets for non-formal education. Quality baskets seek to improve pupils academic achievements. EUR 30,324,2001 were allocated to this programme across 270 schools. The programme includes the evaluation of schools, provision of improvement plans to the schools and the monitoring of their success. Meanwhile, financial baskets for non-formal education seek to improve childrens attendance in non-formal education by providing every child with a monthly allowance to purchase non-formal education activities. All-day schools are settings in which children are provided with educational activities after official school hours. The main goals of these schools are to improve the inclusion of children from vulnerable backgrounds and to reduce conflicts between parents family life and work commitments. Day care centres are social care settings in which children from the most vulnerable backgrounds (such as families at social risk) gather after school and receive help with their homework, participate in various educational and cultural activities, and receive free meals. These centres also seek to work with childrens parents to improve their parenting skills and to ensure that children receive all the support they need. Despite improved financial allocations and more attention being given to the parents, the hidden costs of education remain, and there is a lack of universal provision of school supplies and other necessary materials. 10Basis for a European Child Guarantee Action Plan in Lithuania Recommendations for improving access to education There should be universal and inclusive education for all children: geographical and socio-economic disparities should be addressed, as well as differences in levels of inclusion and quality among schools. Universality and equality in the education system would reduce inequality between children from families of different socio-economic status. It would also improve academic achievement and decrease school dropouts. It is necessary to provide all children with school supplies, transport and meals to reduce hidden costs and bullying in schools. It is also important to address such differences as the unequal distribution of learning support specialists, laboratories, IT infrastructure and high-quality teaching staff among schools, and to reduce differences between elite and rural as well as minority schools. Reducing inequalities between schools would also improve the inclusion of children with SEN and children with migrant backgrounds. Targeted interventions should also take place to improve boys academic achievements. Update curricula and provide greater flexibility in the selection and design of programmes. It is crucial to enrich learning experiences while supporting the effective use of digital technologies and encouraging activities that link learning with real-life experience. It is also necessary to improve the curricula in vocational schools so that they effectively combine strong basic and job-related skills. Regions, cities and schools should be allowed to choose from a list of validated activities and programmes that best meet the needs of their children. Greater investment in measures that reduce early school leaving. Interdisciplinary communication is crucial to ensure that children who are not well included in schools are identified and worked with, to reduce the risk of dropouts. It is also necessary to improve communication with childrens parents, to ensure that they receive all the necessary information and that their individual needs and those of their children are met. Preventive and tailored interventions that involve multiple actors (such as families, schools, and so on) are identified as being more likely to succeed. Developing early warning systems for pupils at risk could help to ensure effective measures are taken before problems become manifest. The availability of various routes back into mainstream education and training is also important. Expand all-day schools and non-formal education opportunities across Lithuania. The lack of teachers and other staff, as well as additional transport costs, learning supplies, additional school meals and the necessity to adapt methodologies, are all concerns that must be addressed in order to ensure the expansion and quality of all-day schools and non-formal education across Lithuania. It is also important to address the issue of access to non-formal education for children living in rural areas, as well as for children with SEN and disabilities. Also important is the need to ensure that a variety of after school activities options are available for these children. Strengthen the teaching workforce. It is important to attract teachers with different backgrounds, genders and ages. All teachers should have a BA degree and at least some should have a Masters degree. Initial teacher education also needs to be improved, and greater flexibility should be provided in terms of the ways in which people can acquire a teaching degree. It is important to ensure that new teachers can work in a well-supported environment and receive frequent feedback and mentoring during the early years of their careers. In addition, all teachers should be provided with qualification courses, and teachers opportunities to network and exchange knowledge and experiences at school should be strengthened and improved. There should be a more coherent career pathway for teachers that rewards teaching excellence. The methods used to recruit teachers should be improved, and salaries should be raised. Set national quality standards and implement monitoring. It is important to prioritize education at policy level as part of the overall solution to social exclusion and poverty throughout the integration process. Any strategy should therefore provide clear timelines, targets, baselines and indicators to monitor progress, as well as adequate financial, material and human resources. External evaluation must be carried out, as well as the provision of methodology and tools for internal evaluation by schools. General quality criteria need to be set as high as possible, while minimum quality thresholds are also required to avoid a lack of balance between regions and avoid a situation in which the quality of a childs education depends on the region in which they are born. Funding on a larger scale should also ensure consistency between richer and poorer regions, to avoid a situation in which municipalities with a higher prevalence of low-income families lack the means to serve the needs of those families. The possibility should be considered of assigning higher weights in the funding formula to socio-economically disadvantaged students. More attention should be devoted to improving efficiency in the allocation and use of school maintenance budgets. PH OTO CR ED IT: U NIC EF - VA KH TAN G K HET AG UR I 4. Free and effective access to healthcare Main challenges experienced by children in Lithuania in relation to healthcare Socio-economic disadvantages negatively influence childrens access to the healthcare system in Lithuania. Childrens medical and dental needs may remain unmet due to various reasons, such as families inability to afford treatment, long waiting lists, long travel times, or no means of transport, as well as a lack of time due to parents work or their responsibility to care for other family members. Children in low-income or single-parent families, Roma families and children living in precarious family situations are at a high risk of not receiving necessary health treatments due to travel costs, lack of time to take children to the doctor, and also due to some necessary and continuous treatments not being entirely free of charge and, in the case of and Roma families families in precarious situations, due to a lack of education and interest in childrens health on the part of parents. One of the most obvious issues is the insufficient level of vaccinations. Vaccination rate among children in Lithuania are lower than the 95 per cent recommended by the WHO, and the issue of non-vaccination is particularly common among Roma children. Another important issue relating to healthcare is a lack of physical activity by children, often determined by the absence of interest by parents and financial reasons. The children who experience the highest risk of low physical activity are those from low-income families, families at social risk, single-parent families and Roma families, as the main reasons for low levels of physical activity include the inability to afford after-school sports activities and/or transportation, lack of time to take children to these activities or to supervise childrens activities on a daily basis, as well as the previously mentioned lack of parents education and interest in their childrens health in the cases of families at social risk and Roma families. These same groups of children do not always have access to mental health services when needed, due to long waiting lists and parents lack of time or transport to take children to consultations, especially when they live in remote rural areas, far away from clinics. The lack of availability of psychological counselling is especially problematic for children from low-income and single-parent families, as their parents often cannot afford private consultations and are even more time-poor than wealthier families. Families raising children with disabilities or special needs report having limited access to certain treatments their children need, as well as a lack of specialists, long waiting periods, and so on. Migrant and refugee children may experience limited access to free healthcare. 11 12Basis for a European Child Guarantee Action Plan in Lithuania Table 3. Number of children in need of free and effective access to healthcare Vulnerable group Estimated size of the group Data source and year Children in low-income families 24% (138,000) of children between birth and the age of 19 are at risk of poverty Eurostat, 2021 Roma children 1,036 Overview of the Roma situation in Lithuania, 2016 Children living in precarious family situations 17,430 Official Statistics Portal, 2018 Migrant and returnee children 4,310 Ministry of Education and Science, 2018OSP, 2020 Children with disabilities 14,289 NGO Confederation for Children, 2017 Children with mental illness 701.05 per 10,000 children The Institute of Hygiene, 2018 Children in single-parent families 26% of all families150,000 children Eurostat, 2017Lithuanian Population and Housing Census, 2011 Policy responses to improve access to healthcareEnsuring childrens health and social well-being is an important part of the national health system in Lithuania. Access to, and the quality of, healthcare services, health literacy, mental and physical health and sex education are at the heart of the National Progress Programme 2021-2030, the Programme of the XVIII Government of the Republic of Lithuania, and the Public Healthcare Development Programme for 2016-2023. Physical activities and mental health services are not currently accessible for all children and their families in Lithuania; thus, the national focus is on spreading awareness of the importance of mental and physical health, increasing access to sporting activities, and improving childrens health monitoring. The National Progress Programme 2021-2030 strategically aims to increase social well-being inclusion within Lithuanias population, and strengthen its health. To achieve this goal, the following measures are planned: improved adaptation of the environment for people with disabilities, including children (e.g. transport, infrastructure, services, information); increased attention to childrens psychological state and access to mental health services; improved access to physical activities for children; high-quality health care services; improved health literacy; an efficient health system with focus on stronger primary care; and improved access to outpatient care. Moreover, issues such as long waiting lists to receive treatment, the high cost of drugs and high levels of corruption are also addressed. However, some healthcare programmes such as continuous rehabilitation services and treatments for certain developmental disorders, as well as transport services, remain among the biggest barriers to accessing healthcare provision for the most vulnerable children in Lithuania. The Programme of the XVIII Government of the Republic of Lithuania plans to improve access to sporting activities and mental health services. The main tools to achieve this include promoting more equal distribution of qualified sports specialists across the country; introducing up to three physical education lessons per week in all general education schools; updating the physical education curriculum; providing swimming lessons to all children in primary schools; improving sex education; and improving access to mental health services. The National Public Healthcare Development Programme for 2016-2023 also seeks to promote physical and mental health, as well as encouraging a healthy lifestyle and culture, by promoting health literacy and ensuring the sustainability of the public health care system. To achieve these goals, awareness will be raised with regard to physical and mental health, with an emphasis on the prevention of illnesses in schools; updating sports 13Basis for a European Child Guarantee Action Plan in Lithuania equipment and facilities in schools; monitoring physical activity and childrens mental state; increasing the availability of high-quality public health care services and improving the management of the public health care system overall. The key mechanism currently used ensure childrens health needs are met is preventive annual health inspections and the National Immunization Programme 2019-2023. The latter provides that all recommended vaccinations included in the national immunization scheme are free of charge. The Programme aims to ensure at least 90 per cent of children are vaccinated (in the case of measles and rubella, not less than 95 per cent) across the country and in each municipality. Meanwhile, preventive annual health examinations at health care institutions include consultations with family doctors and dentists, and are compulsory for all children attending pre-primary and general education. However, a lack of attention is paid to the health of children who fall outside formal care and education systems. Attending to the medical needs of these children depends solely on their parents who, as previously mentioned, may lack interest or knowledge about their childrens health. A grey area also exists with regard to refugee children, who have different rights to the nationals in terms of access to healthcare. Meanwhile, children with disabilities receive financial assistance and various free services. These include a social assistance pension; targeted compensation for assistance costs for children with disabilities; and universal and free early rehabilitation for children with developmental disorders. The mechanism for integrated family services includes the provision of positive parenting training, psychological counselling, ECEC services, transport and more. Nevertheless, many issues still remain for children with SEN and disabilities, who face additional challenges in addressing everyday medical needs such as dental treatment. They also lack access to special, targeted treatments and integrated assistance that could help to meet all of their needs and reduce the burden on their families. Recommendations for improving access to healthcare Consistent coordination between central and local institutions is necessary in order to ensure

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