Global immunization and culture: compliance and resistance in large-scale public health campaigns

In Torlak we (would) trust: domestic vaccine production in contemporary Serbia

Throughout the era of socialist Yugoslavia, the Institute of Virology, Vaccines and Sera 'Torlak' in Belgrade was a well known producer and exporter of vaccines. After the dissolution of the country, it gradually lost its significance in both global and domestic vaccine markets. However, in Serbian public discourse, Torlak's vaccines are still remembered as of the highest quality. Many people would willingly vaccinate themselves or their children with Torlak's vaccines. But how do overly positive Yugoslav vaccination experiences influence vaccination narratives in contemporary postsocialist Serbia? To answer this question, I analysed electronic word of mouth from 2005 until 2020 from Serbia's main daily news sources. Public narratives on Torlak's vaccine production seem to be a local response and a consequence of global changes in the international vaccine market. Furthermore, this study shows that public calls for the revival of Torlak's vaccine production are part of wider public yearning for 'normal life' in postsocialist Serbia. In this respect, positive memories of Torlak vaccines do not serve as a strategy for dealing with the past. As a special form of Yugo-nostalgia and as a 'material embodiment' of normal life under socialism, narratives represent a strategy for dealing with the present: a therapy for dealing with the 'abnormality' of life in today's Serbia. Contemporary public vaccination attitudes are shaped both by collective memory of the production and administration of Torlak's vaccines in socialist Yugoslavia, and by narratives on Torlak's unfavourable current position. They also reflect wider opinions, hopes and yearning for the restoration of the country's political, health and economic institutions.

The impact of access to immunization information on vaccine acceptance in three countries

Introduction

Vaccine acceptance is a critical component of sustainable immunization programs, yet rates of vaccine hesitancy are rising. Increased access to misinformation through media and anti-vaccine advocacy is an important contributor to hesitancy in the United States and other high-income nations with robust immunization programs. Little is known about the content and effect of information sources on attitudes toward vaccination in settings with rapidly changing or unstable immunization programs.

Objective

The objective of this study was to explore knowledge and attitudes regarding vaccines and vaccine-preventable diseases among caregivers and immunization providers in Botswana, the Dominican Republic, and Greece and examine how access to information impacts reported vaccine acceptance.

Methods

We conducted 37 focus groups and 14 semi-structured interviews with 96 providers and 153 caregivers in Botswana, the Dominican Republic, and Greece. Focus groups were conducted in Setswana, English, Spanish, or Greek; digitally recorded; and transcribed. Transcripts were translated into English, coded in qualitative data analysis software (NVivo 10, QSR International, Melbourne, Australia), and analyzed for common themes.

Results

Dominant themes in all three countries included identification of health care providers or medical literature as the primary source of vaccine information, yet participants reported insufficient communication about vaccines was available. Comments about level of trust in the health care system and government contrasted between sites, with the highest level of trust reported in Botswana but lower levels of trust in Greece.

Conclusions

In Botswana, the Dominican Republic, and Greece, participants expressed reliance on health care providers for information and demonstrated a need for more communication about vaccines. Trust in the government and health care system influenced vaccine acceptance differently in each country, demonstrating the need for country-specific data that focus on vaccine acceptance to fully understand which drivers can be leveraged to improve implementation of immunization programs.

Factors affecting access to information on routine immunization among mothers of under 5 children in Kaduna State Nigeria, 2015

INTRODUCTION

Immunization is one of the most effective interventions to prevent disease and early child death. A substantial number of children worldwide do not complete immunization schedules because neither health services nor conventional communication mechanisms regularly reach their communities. Knowledge and perception of mothers/caregivers regarding VPDs influence demand and utilization of immunization services. We examined the associations between knowledge, perception and information on routine immunization received by mothers/caregivers in Kaduna State.

METHODS

We enrolled 379 eligible caregivers in a community-based cross-sectional study. We sampled respondents using multistage sampling technique. We collected data on socio-demographic characteristics; knowledge and perception on routine immunization using semi-structured interviewer-administered questionnaire. We conducted bivariate analysis and logistic regression using Epi-InfoTM version 7 at 5% level of significance.

RESULTS

Mean age of respondents was 28.6 years (standard deviation=±6.6 years), 34% completed secondary school, 65% were unemployed, 49% lived in rural settlements. Among respondents' children 53.3% were females and 62.8% fell within 2nd-5th birth order. Only 15.6% of these children were fully immunized. Seventy-five percent of respondent did not obtain information on routine immunization within 12 months prior to the study. About 64% had unsatisfactory knowledge while 55.4% exhibited poor perceptions regarding routine immunization. Commonest source of information was radio (61.61%). On logistic regression educated participants (Adjusted odds ratio (AOR)=1.9, 95% CI: 1.1-3.3), mothers' perception (AOR=2.6, 95% CI: 1.5-4.5) and monogamous family setting (AOR=2.4, 95% CI: 0.2-0.6) were likely to have obtained information on routine immunization.

CONCLUSION

There is low access to information, poor maternal knowledge on routine immunization with low vaccination coverage in this community. Efforts should be made by the Governments to scale up sensitization of mothers/caregivers to improve their knowledge on routine immunization through radio jingles.

Coercion and polio eradication efforts in Moradabad

We introduce the problem of vaccine coercion as reported in Moradabad, India. We offer commentary and critical analysis on ethical complexities at the intersection of global public health and regional political strife and relate them to broader vaccine goals. We draw upon a historical example from malaria vaccine efforts, focusing specifically on ethical and health justice issues expressed through the use of coercion in vaccine administration. We suggest how coercion is indicative of failed leadership in public health and consider community-based collaborations as models for cultivating local investment and trust in vaccination campaigns and for success in global public health initiatives.

Global public health mandates in a diverse world: the polio eradication initiative and the expanded programme on immunization in sub-Saharan Africa and South Asia

BACKGROUND

The circulation of wild poliovirus is expected to cease soon due to the success of the global polio eradication initiative. Thereafter, intensified polio eradication efforts such as National Immunisation Days (NIDs) will most likely be discontinued. As a consequence, the expanded programme on immunization (EPI) will no longer enjoy extra inputs from the polio eradication initiative. We investigated whether today's EPIs are ensuring universal and equitable vaccine coverage; and whether the removal of extra inputs associated with the implementation of NIDs is likely to affect EPI coverage and equity.

METHODS

Using data from Demographic and Health Surveys conducted in 15 countries of South Asia and Africa during 1990-2001, we examined absolute levels of EPI coverage; changes in EPI coverage after the introduction of NIDs; and relative coverage according to urban versus rural residence, higher versus lower education of mothers, and wealthiest vs. poorest population segment.

RESULTS

Polio and non-polio antigen coverage increased in seven countries during the study period. Substantial inequalities in coverage of non-polio antigens persist, however, translating into inequities in the risk of contracting vaccine preventable diseases. In some African countries, routine EPI coverage and/or equity declined during the study period. In these countries, any positive effect of NIDs on the EPI coverage must have been small, relative to the negative effects of declining economies or deteriorating health systems. In Nigeria, Zimbabwe, Kenya and Malawi, even polio coverage declined, in spite of the introduction of NIDs.

CONCLUSION

As additional inputs associated with polio eradication will cease, routine EPI services need to be strengthened substantially in order to maintain levels of population immunity against polio and to improve social equity in the coverage of non-polio EPI antigens. Our findings imply that this aim will require additional inputs, particularly in African countries.

The impact of the national polio immunization campaign on levels and equity in immunization coverage: evidence from rural North India

Few studies have investigated the impact of immunization campaigns conducted under the global polio eradication program on sustainability of polio vaccination coverage, on coverage of non-polio vaccines (administered under Expanded Program on Immunization (EPI)), and on changes in social inequities in immunization coverage. This study proposes to fill the gaps in the evidence by investigating the impact of a polio immunization campaign launched in India in 1995. The study uses a before-and-after study design using representative samples from rural areas of four North Indian states. The National Family Health Survey I (NFHS I) and NFHS II, conducted in 1992-93 and 1998-99 respectively, were used as pre- and post-intervention data. Using pooled data from both the surveys, multivariate logistic regression models with interaction terms were used to investigate the changes in social inequities. During the study period, a greater increase was observed in the coverage of first dose of polio compared to three doses of polio. Moderate improvements in at least one dose of non-polio EPI vaccinations, and no improvements in complete immunization against non-polio EPI diseases were observed. The polio campaign was successful, to some extent, in reducing gender-, caste- and wealth-based inequities, but had no impact on religion- or residence-based inequities. Social inequities in non-polio EPI vaccinations did not reduce during the study period. Significant dropouts between first and third dose of polio raise concerns of sustainability of immunization coverage under a campaign approach. Similarly, little evidence to support synergy between polio campaign and non-polio EPI vaccinations raises questions about the effects of polio campaign on routine health system's functions. However, moderate success of the polio campaign in reducing social inequities in polio coverage may offer valuable insights into the routine health systems for addressing persistent social inequities in access to health care.

Trust, learning, and vaccination: a case study of a North Indian village

For US 17 dollars a child can be immunized against six major illnesses. Even at this price, a country such as India would have to spend half its health budget on providing vaccinations. Given the wide variation in immunization costs it may be possible to decrease this cost to more sustainable levels, but to do so we need to arrive at a more thorough understanding of factors affecting household demand for vaccination. Using data on vaccination and pre-natal care collected by the authors in the Garhwal region of India, we explore one aspect of the demand for vaccination in some detail. We show that informational constraints play an important role in the household decision to seek vaccination, and moreover, that learning about the efficacy of vaccinations only through empirical observation may be hard even in environments with variation in vaccination and the high incidence of vaccine-preventable diseases. We argue that when learning about vaccination is inefficient, households use concurrent interventions with easily observable outcomes to evaluate the veracity of a provider's claim regarding preventive care. Hence, the success of immunization programs becomes crucially linked to the success of parallel programs by the same provider.

When acculturation hurts: the case of immunization

The study examined the relationship between the acculturation of Mexican American mothers in Texas and immunization status of their children between 3 and 24 months of age. Mothers' acculturation, demographic characteristics, and immunization status of their children were assessed in in-person interviews with a sample of Mexican American respondents representative for Texas (n = 2193). Acculturation was measured with ten scales assessing oral and written language use, proficiency, and preference, music and TV viewing preferences, ethnic identity, place where a person was reared, and contacts with Mexico. Immunization status, defined according to the recommendation of the CDC Advisory Committee on Immunization Practices, was determined from official shot records obtained directly from respondents or, for respondents without records, obtained from their health care providers. Regression analysis revealed that acculturation significantly contributed to inadequate immunization status, even when socioeconomic status and other demographic covariates of acculturation were statistically controlled. Mediational analysis revealed that acculturation contributed to inadequate immunization through less positive attitudes toward immunization, a diminished sense of parental responsibility for children's immunization, and more perceived barriers to immunization. It is concluded that culture-specific beliefs encouraging childhood immunization should be fostered among Mexican Americans.