Perspectives on polio and immunization in Northern Nigeria

Can endorsement by religious leaders move the needle on vaccine hesitancy?

Existing research, including work specific to COVID-19, suggests that endorsement by medical practitioners increases vaccine uptake. Yet, vaccine hesitancy persists despite health professionals continuing to widely endorse multiple vaccines to combat COVID-19 since late 2020. Could endorsement by other trusted leaders reduce vaccine hesitancy? Although some studies suggest that trust in religious leaders can influence individuals' health attitudes and behaviors, the evidence is mixed. Our study explores the potential added value of messaging by religious leaders across religious traditions - specifically, it asks whether their endorsement of the COVID-19 vaccine might increase vaccine uptake in an environment where health professionals are already endorsing vaccines. To investigate this question, we conducted an online survey experiment with 6,000 respondents across five countries with different dominant religions (Buddhism, Christianity, and Islam). Respondents were randomly assigned to either a control group that only included endorsement by medical practitioners or a treatment group that added either endorsement by religious leaders or, for comparative purposes, endorsement by political leaders. We found that endorsement by religious leaders reduced vaccine hesitancy only in one country. These findings corroborate existing research that medical practitioners are the best line of defense to combat vaccine hesitancy. They also suggest the limitations of endorsement by non-experts.

Trends in childhood immunisation amongst Muslim children of Punjab (India): An empirical study

India's immunisation programme is one of the largest in the world and achieved great success over the years, however, some significant gaps are still observable in terms of achieving universal immunisation of children. Religion has emerged as a strong correlate for immunisation rates at national, state and global level. It has been observed that the rate of immunisation among children from Muslim families is comparatively less at global as well as at national level. Therefore, the paper attempts to understand immunisation trends among Muslims children from the north-western Indian state of Punjab. Based on the cross-sectional study of 400 households from district Sangrur of Punjab, results of the study show that rate of full immunisation among children from Muslim families was 88 per cent and none of the children were non-immunised. Reasons stated for partial immunisation of children included distrust of the government and belief that it would cause infertility amongst children. The present study reveals that religion per se does not appear to be influence rates of full immunisation. Geographical location, embeddedness of the community in the larger political and social milieu of their area, reach and acceptance of health workers at grassroots level emerge as strong factors contributing to higher rates of immunisation amongst Muslim children of Malerkotla.

"What is the problem with vaccines?" A typology of religious vaccine skepticism

Research has identified religion as one of numerous factors that may contribute to delay or refusal of vaccination. The influence of religion on vaccine decisions may be accidental, or it may involve explicit religious objections. By presenting a typology of religious vaccine skepticism, this article seeks to give a comprehensive overview of the essence of these objections and to clarify differences and similarities between them. This knowledge is useful for policy-makers and others who wish to better understand the influence of religion on vaccine decision-making. The typology consists of five main types: (1) a worldview clash type, in which vaccines do not make sense as a health intervention; (2) a divine will type, which represents a form of passive fatalism; (3) an immorality type, which considers some vaccines unethical because of their production or effect; (4) an impurity type, pointing to ingredients that will defile the body; and (5) a conspiracy type, in which a vaccine plot is targeting a religious group.

Polio-philanthropy in Africa: A narrative review

Background and Aim

Polio eradication efforts including polio-philanthropy have been coordinated and sustained since 1988, with the introduction of the Global Polio Eradication Initiative (GPEI). The polio fight is sustained in the name of evidence-based benevolence or beneficent philanthropy from which Africa has benefited immensely. With the recorded polio cases as of 2023, more efforts and funds are required to eradicate polio. Hence, it is not yet "Uhuru." Using the Mertonian lens, this study examines polio-philanthropy in Africa, its unintended consequences, and crucial dilemmas, which could impact the polio fight and polio-philanthropy.

Methods

This is a narrative review that relies on secondary sources obtained through a thorough literature search. Only studies published in English were utilized. The study synthesized relevant literature in line with the study objective. The following databases were consulted: PubMed, philosopher's index, web of knowledge, Google Scholar, and Sociological Abstracts. Both empirical and theoretical studies were utilized for the study.

Results

Despite significant achievements, the global initiative has shortcomings when examined through the Mertonian lens of manifest and latent functions. The GPEI sets a unilinear goal within multiple challenges. The activities of the philanthropic giants manifest in disempowering rigor, multisectoral neglect, and parallel (health) systems, sometimes, inimical to the national health system. Most philanthropic giants often operate vertically. It is observed that, apart from funding, the last phase of polio-philanthropy will be defined by some crucial factors, the 4Cs: Communicable disease outbreaks, Conflict, Climate-related disasters, and Conspiracy theory, which could impact the prevalence or resurgence of polio.

Conclusion

The polio fight will benefit from the persistent drive to reach the finish line as scheduled. The latent consequences or dysfunctions are general lessons for GPEI and other global health initiatives. Therefore, decision-makers should calculate the net balance of consequences within global health philanthropy for appropriate mitigation.

HPV vaccination acceptance and perceptions related to fertility and population control in the Gambia: An anthropological analysis

This qualitative study using in-depth interviews and focus group discussions is the first to investigate HPV vaccination in The Gambia; it provides an in-depth analysis of uptake, knowledge, and perceptions of HPV vaccination as well as trust in Ministry of Health vaccination advice. Despite high uptake rates, knowledge of HPV vaccination was low, and the most prominent concern was that the vaccine could cause infertility or is a form of population control. Holistic approaches to addressing HPV vaccine concerns relating to fertility that consider socio-political contexts, including colonial histories, could lead to more positive vaccine perceptions, empowered decisions and to increasing vaccine uptake rates in The Gambia and elsewhere.

A Systematic Review of Factors That Influence Parents’ Views and Practices around Routine Childhood Vaccination in Africa: A Qualitative Evidence Synthesis

A Cochrane review which explored the factors that influence caregivers’ views and practices around routine childhood vaccines worldwide was conducted by Cooper and colleagues. After sampling 154 studies that met their inclusion criteria, the authors included 27 studies in their synthesis, of which 6 were from Africa. The aim of the current review was to synthesise all 27 studies conducted in Africa. We wanted to determine if the inclusion of additional African studies will change any of the themes, concepts or theory generated in the Cochrane review. Our review found that parents’ views and practices regarding childhood vaccination in Africa were influenced by various factors, which we categorised into five themes, namely, ideas and practices surrounding health and illness (Theme 1); social communities and networks (Theme 2); political events, relations, and processes (Theme 3); lack of information or knowledge (Theme 4); and access-supply-demand interactions (Theme 5). All of the themes identified in our review were also identified in the Cochrane review except for one theme, which was lack of information or knowledge. This finding will help to promote vaccine acceptance and uptake in Africa by developing and implementing interventions tailored to address lack of knowledge and information around vaccines.

A light touch intervention with a heavy lift - gender, space and risk in a global vaccination programme

Frontline workers (FLWs) in the Global Polio Eradication Initiative go door-to-door delivering polio vaccine to children. They have played a pivotal role in eliminating wild polio from most countries on earth; at the same time, they face significant bodily risk. STRIPE, an international consortium, conducted a mixed-methods study exploring the knowledge and experiences of polio staff in seven countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We surveyed 826 polio FLWs and conducted semi-structured interviews with 22 of them. We used a body work framework to guide analysis. Polio workers perform a different kind of body work than many other FLWs. Delivering a few drops of oral vaccine takes a light touch, but gendered spaces can make the work physically dangerous. Polio's FLWs must bend or break gendered space norms as they move from house-to-house. Navigating male spaces carries risk for women, including lethal risk, particularly in conflict settings. Workers manoeuvre between skeptical community members and the demands of supervisors which generates emotional labour. Providing FLWs with more power to make operational decisions and providing them with robust teams and remuneration would improve the likelihood that they could act to improve their working conditions.

The Excluded Voices from Africa's Sahel: Alternative Meanings of Health in Narratives of Resistance to the Global Polio Eradication Initiative in Northern Nigeria

Although previous inquiry into resistance to the polio vaccines in northern Nigeria has been launched from several disciplines, inquiry has been limited to the 2003 revolt and has rarely been informed by theory. This study drew on the culture-centered approach to health communication to argue that the exclusion of marginalized communities from decision-making by the Global Polio Eradication Initiative (GPEI) resulted in a vaccine resistance which found expression in health activism that engaged the local news media. To recover the excluded voices, this study examined community members' narratives of resistance to the vaccines in Nigerian news from 2012 to 2018. Upon providing a backdrop for these narratives through a chronology of GPEI milestones in northern Nigeria developed from Nigerian newspapers, the study then engaged with 168 speech acts of resistance in Nigerian news to co-construct alternative meanings of health. Drawing on a local cultural meaning of the vaccines as covertly carrying out a Western family-planning agenda, narrators negligibly associated "family planning" with health. Narrators further articulated health as access to foods and as religious practice. These findings have implications for the inclusion of voices from sub-Saharan Africa in GPEI decision-making.

Between Healthcare Practitioners and Clergy: Evangelicals and COVID-19 Vaccine Hesitancy

Evangelical Christians are among the most hesitant to get the COVID-19 vaccine. This study examined the extent to which COVID-19 vaccination uptake among Evangelicals is explained by demographic characteristics, Health Belief Model constructs, and faith-based support factors. Survey research firm Qualtrics recruited 531 U.S. adults and conducted a survey to explore predictors of COVID-19 vaccine uptake among people who self-identified as Evangelicals in September 2021. A logistic regression showed that those reporting high perceived benefits of the COVID-19 vaccine were more likely to be vaccinated, while those reporting high perceived barriers were less likely to be vaccinated. Those whose healthcare provider asked them about the vaccine were more likely to be vaccinated than those whose healthcare provider did not ask. Finally, while those who reported information seeking from religious leaders were less likely to be vaccinated, those who reported more faith-based support for vaccination were more likely to be vaccinated. In addition to beliefs about benefits and barriers to vaccination, the role of healthcare providers and clergy were important factors influencing vaccination status. Intervention efforts that capitalize on partnerships between health providers and clergy in supportive congregations may be able to reach undecided Evangelicals.

"Are You Sure It's Not the Corona Vaccine?" An Ebola Vaccine Trial During COVID-19 in DRC

The COVID-19 pandemic began as an Ebola epidemic was unfolding in the Democratic Republic of the Congo. In this article, we examine how COVID-19 influenced experiences of an Ebola vaccine trial and attitudes towards medical research in Goma. First, critical debates about vaccine research became a forum in which to contest ineffective local governance and global inequality. Second, discussions about new COVID-19 therapeutics reignited critique of Western biomedical colonialism. Third, rumors were made powerful through everyday observations of the unexpected adaption of Ebola trial procedures in the pandemic. This illustrates the difficulties of maintaining participants' trust, when circumstances dictate protocol alterations mid-trial.

Factors affecting recommended childhood vaccine demand

Reaching a high vaccination coverage level is of vital essence when preventing epidemic diseases. For mandatory vaccines, the demand can be forecasted using some demographics such as birth rates or populations between certain ages. However, it has been difficult to forecast non-mandatory vaccine demands because of vaccine hesitation, alongside other factors such as social norms, literacy rate, or healthcare infrastructure. Consequently, the purpose of this study is to explore the predominant factors that affect the non-mandatory vaccine demand, focusing on the recommended childhood vaccines, which are usually excluded from national immunization programs. For this study, fifty-nine factors were determined and categorized as system-oriented and human-oriented factors. After a focus group study conducted with ten experts, seven system-oriented and eight human-oriented factors were determined. To reveal the cause and effect relationship between factors, one of the multi-criteria decision-making methods called Fuzzy-DEMATEL was implemented. The results of the analysis showed that “Immunization-related beliefs”, “Media/social media contents/messaging”, and “Social, cultural, religious norms” have a strong influence on non-mandatory childhood vaccine demand. Furthermore, whereas “Availability and access to health care facilities” and “Political/ financial support to health systems” are identified as cause group factors, “Quality of vaccine and service delivery management” is considered an effect group factor. Lastly, a guide was generated for decision-makers to help their forecasting process of non-mandatory vaccine demands to avoid vaccine waste or shortage.

"I let others speak about condoms:" Muslim religious leaders' selective engagement with an NGO-Led family planning project in rural Tanzania

In the past two decades, religious leaders have garnered increased interest from health ministries and NGOs as promoters, educators, and implementers of sensitive health programs such as family planning in several African countries. While religious leaders' role as public health actors has been well-documented, there are few ethnographic accounts of how religious leaders engage with public health programs, especially family planning. Informed by twelve months of ethnographic study in three rural and peri-urban locations in Kilombero district in 2014-2016, this article examines how Muslim religious leaders experienced and negotiated their role as implementers of family planning services. Governments and NGOs seek religious leaders' social capital to increase community's knowledge of and demand for family planning as well as to diffuse the community's moral anxieties surrounding its use. Participant observation and interviews, however, show that religious leaders selectively engage with family planning projects, balancing project demands, their own interests and the existing norms and perceptions in the community. Religious leaders stood beside other team members promoting condoms, but they remained silent themselves on condom promotion selecting instead to speak on the dangers of teenage pregnancy. Tensions, power differentials and a mélange of interests, existing and emergent, set the stage for religious leaders to selectively engage with the family planning project. Selective engagement was beneficial for both parties. Religious leaders received training on modern family planning, gained symbolic capital by associating with a powerful NGO, and expanded their social networks while government officials and NGOs received indirect support for family planning programs.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Assessing community engagement in Nigeria polio eradication initiative: application of the Consolidated Framework for Implementation Research

OBJECTIVE

This study employed the Consolidated Framework for Implementation Research (CFIR) to assess factors that enhanced or impeded the implementation of community engagement strategies using the Nigerian polio programme as a point of reference.

DESIGN

This study was a part of a larger descriptive cross-sectional survey. The CFIR was used to design the instrument which was administered through face-to-face and phone interviews as well as a web-based data collection platform, Qualtrics.

SETTING

The study took place in at least one State from each of the six geopolitical zones in Nigeria (Nasarawa, Borno, Kano, Sokoto, Anambra, Bayelsa, Lagos, Ondo and Oyo States as well as the Federal Capital Territory).

PARTICIPANTS

The respondents included programme managers, policy-makers, researchers and frontline field implementers affiliated with the Global Polio Eradication Initiative (PEI) core partner organisations, the three tiers of the government health parastatals (local, state and federal levels) and academic/research institutions.

RESULTS

Data for this study were obtained from 364 respondents who reported participation in community engagement activities in Nigeria's PEI. Majority (68.4%) had less than 10 years' experience in PEI, 57.4% were involved at the local government level and 46.9% were team supervisors. Almost half (45.0%) of the participants identified the process of conducting the PEI program and social environment (56.0%) as the most important internal and external contributor to implementing community engagement activities in the community, respectively. The economic environment (35.7%) was the most frequently reported challenge among the external challenges to implementing community engagement activities.

CONCLUSION

Community engagement strategies were largely affected by the factors relating to the process of conducting the polio programme, the economic environment and the social context. Therefore, community engagement implementers should focus on these key areas and channel resources to reduce obstacles to achieve community engagement goals.

30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation

Introduction

The debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time.

Methods

We constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication.

Results

Pursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise.

Conclusion

It benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate. 

"If a rabbi did say 'you have to vaccinate,' we wouldn't": Unveiling the secular logics of religious exemption and opposition to vaccination

Maintaining 'faith' in vaccination has emerged as a public health challenge amidst outbreaks of preventable disease among religious minorities and rising claims to 'exemption' from vaccine mandates. Outbreaks of measles and coronavirus have been particularly acute among Orthodox Jewish neighbourhoods in North America, Europe and Israel, yet no comparative studies have been conducted to discern the shared and situated influences on vaccine decision-making. This paper synthesises qualitative research into vaccine decision-making among Orthodox Jews in the United Kingdom and Israel during the 2014-15 and 2018-19 measles epidemics, and 2020-21 coronavirus pandemic. The methods integrate 66 semi-structured informal interviews conducted with parents, formal and informal healthcare practitioners, and religious leaders, as well as analysis of tailored non-vaccination advocacy events and literature. The paper argues that the discourse of 'religious' exemption and opposition to vaccination obscures the diverse practices and philosophies that inform vaccine decisions, and how religious law and leaders form a contingent influence. Rather than viewing religion as the primary framework through which vaccine decisions are made, Orthodox Jewish parents were more concerned with safety, trust and choice in similar ways to 'secular' logics of non-vaccination. Yet, religious frameworks were mobilised, and at times politicised, to suit medico-legal discourse of 'exemption' from coercive or mandatory vaccine policies. By conceptualising tensions around protection as 'political immunities,' the paper offers a model to inform social science understandings of how health, law and religion intersect in contemporary vaccine opposition.

Some lessons for malaria from the Global Polio Eradication Initiative

The Global Polio Eradication Initiative (GPEI) was launched in 1988 with the aim of completely clearing wild polio viruses by 2000. More than three decades later, the goal has not been achieved, although spectacular advances have been made, with wild polio virus reported in only 2 countries in 2019. In spite of such progress, novel challenges have been added to the equation, most importantly outbreaks of vaccine-derived polio cases resulting from reversion to neurovirulence of attenuated vaccine virus, and insufficient coverage of vaccination. In the context of the latest discussions on malaria eradication, the GPEI experience provides more than a few lessons to the malaria field when considering a coordinated eradication campaign. The WHO Strategic Advisory Committee on Malaria Eradication (SAGme) stated in 2020 that in the context of more than 200 million malaria cases reported, eradication was far from reach in the near future and, therefore, efforts should remain focused on getting back on track to achieve the objectives set by the Global Technical Strategy against Malaria (2016–2030). Acknowledging the deep differences between both diseases and the stages they are in their path towards eradication, this paper draws from the history of GPEI and highlights relevant insights into what it takes to eradicate a pathogen in fields as varied as priority setting, global governance, strategy, community engagement, surveillance systems, and research. Above all, it shows the critical need for openness to change and adaptation as the biological, social and political contexts vary throughout the time an eradication campaign is ongoing.

Factors contributing to the uptake of childhood vaccination in Galkayo District, Puntland, Somalia

Background

As in many Sub-Saharan African countries, the health system in Somalia is not operating at the capacity needed to lift childhood vaccination coverage to ninety percent or above, as recommended by United Nations Children’s Fund. Current national estimates of coverage for the six major vaccine preventable childhood diseases range from thirty to sixty percent. Infectious disease outbreaks continue to pose significant challenges for the country’s health authorities.

Objective

This important qualitative study, conducted in Galkayo District, Somalia, investigates limiting factors associated with childhood vaccination uptake from the perspective of both communities and health care workers.

Methods

Qualitative information was collected through six focus group discussions with parents (n = 48) and five one-to-one interviews with health workers (n = 15) between March and May 2017, in three settings in the Galkayo District – Galkayo city, Bayra and Bacadwayn.

Results

From a health system perspective, the factors are: awareness raising, hard to reach areas, negative attitudes and perceived knowledge of health workers, inadequate supplies and infrastructure, and missed vaccination opportunities. From the perspective of individuals and communities the factors are: low trust in vaccines, misinterpretation of religious beliefs, vaccine refusals, Somalia’s patriarchal system and rumours and misinformation. Parents mostly received immunization information from social mobilizers and health facilities. Fathers, who are typically family decision-makers, were poorly informed. The findings highlight the need for in-service training to enable health workers to improve communication with parents, particularly fathers, peripheral communities and local religious leaders.

Conclusions

Enhancing knowledge and awareness of vaccination among parents is crucial. Fathers’ involvement is lacking. This may be boosted by highlighting fathers’ obligation to protect their children’s health through vaccination. It is also important that men engage with the wider community in decision-making and advance towards the global vaccination targets.

Ethnicity as a cultural factor influencing complete vaccination among children aged 12-23 months in Nigeria

Achieving complete vaccination for children has been challenging in Nigeria. Yet, addressing Nigeria's completeness of vaccination requires ethno-cultural diversity consideration rather than nationally population based. This study explored patterns and determinants of complete vaccination among children of Hausa/Fulani, Igbo and Yoruba, the predominant ethnicities in Nigeria. The study used a cross-sectional data involving 3980 children aged 12-23 months extracted from the 2018 Nigeria Demographic and Health Survey dataset. In this study, complete vaccination is defined as a child who received all recommended vaccinations. A generalized linear mixed model applied to clustered data was used for data analysis (α = 0.05). The prevalence of complete vaccinations was 56.3%, 40.8% and 18.2% among Igbo, Yoruba and Hausa/Fulani children, respectively. The likelihood of complete vaccination was higher among children who were of Igbo (aOR = 1.38; CI: 1.20-1.59) compared with Hausa/Fulani. Predictors of complete vaccination were maternal age-at-childbirth, education, prenatal-care attendant and place of delivery among Hausa/Fulani; place of residence and perceived access to self-medical help, among Igbo; while prenatal-care attendance, among Yoruba. The odds of complete vaccination were higher among Hausa/Fulani (aOR = 1.65; CI: 1.04-2.61), Igbo (aOR = 2.55; CI: 1.20-5.44) and Yoruba (aOR = 4.22; CI: 1.27-13.96) children from higher wealth-quintile households compared to those from poor households. There was evidence of variability in the likelihood of complete vaccination in all the ethnic groups. The Hausa/Fulani tribe had the lowest complete vaccination coverage for children aged 12-23 months. Context-specific program intervention to improve complete vaccination is needed to ensure that the SDG target for vaccination is met.

The role of place of residency in childhood immunisation coverage in Nigeria: analysis of data from three DHS rounds 2003-2013

Background

In 2017, about 20% of the world’s children under 1 year of age with incomplete DPT vaccination lived in Nigeria. Fully-immunised child coverage (FIC), which is the percentage of children aged 12–23 months who received all doses of routine infant vaccines in their first year of life in Nigeria is low. We explored the associations between child, household, community and health system level factors and FIC, in particular focussing on urban formal and slum, and rural residence, using representative Nigeria Demographic Health Survey (NDHS) data from 2003, 2008 and 2013.

Method

Multilevel logistic regression models were applied for quantitative analyses of NDHS 2003, 2008 and 2013 data, singly, pooled overall and stratified by rural/urban, and within urban by formal and slum. We also quantify Population Attributable Risk (PAR) of FIC.

Results

FIC for rural, urban formal and slum rose from 7.4, 25.6 and 24.9% respectively in 2003 to 15.8, 45.5 and 38.5% in 2013, and varied across sociodemographics. In pooled NDHS analysis, overall and stratified, final FIC adjusted odds (aOR) were: 1. Total population - delivery place (health facility vs home, aOR = 1.13, 95% CI = 0.73–1.73), maternal education (higher vs no education, aOR = 3.92, 95% CI = 1.79–8.59) and place of residence (urban vs rural, aOR = 1.69, 95% CI = 0.89–3.22). 2. Rural, urban formal and slum stratified: A.Rural – delivery place (aOR = 1.47, 95% CI = 1.12–1.94), maternal education (aOR = 4.99, 95% CI = 2.48–10.06). B.Urban formal - delivery place (aOR = 2.62, 95% CI = 1.43–4.79), maternal education level (aOR = 9.18, 95% CI = 3.05–27.64). C.Slums - delivery place (aOR = 5.39, 95% CI = 2.18–13.33), maternal education (aOR = 5.03, 95% CI = 1.52–16.65). The PAR revealed the highest percentage point increase in FIC would be achieved in all places of residence by maternal higher education: rural-38.15, urban formal-22.88 and slum 23.76, while non-attendance of antenatal care was estimated to lead to the largest reduction in FIC.

Conclusion

Although low FIC in rural areas may be largely due to lack of health facilities and immunisation education, the intra-urban disparity is mostly unexplained, and requires further qualitative and interventional research. We show the FIC point increase that can be achieved if specific sociodemographic variable (risk) are addressed in the various communities, thus informing prioritisation of interventions.

Defining hard-to-reach populations for vaccination

Extending the benefits of vaccination to everyone who is eligible requires an understanding of which populations current vaccination efforts have struggled to reach. A clear definition of "hard-to-reach" populations - also known as high-risk or marginalized populations, or reaching the last mile - is essential for estimating the size of target groups, sharing lessons learned based on consistent definitions, and allocating resources appropriately. A literature review was conducted to determine what formal definitions of hard-to-reach populations exist and how they are being used, and to propose definitions to consider for future use. Overall, we found that (1) there is a need to distinguish populations that are hard to reach versus hard to vaccinate, and (2) the existing literature poorly defined these populations and clear criteria or thresholds for classifying them were missing. Based on this review, we propose that hard-to-reach populations be defined as those facing supply-side barriers to vaccination due to geography by distance or terrain, transient or nomadic movement, healthcare provider discrimination, lack of healthcare provider recommendations, inadequate vaccination systems, war and conflict, home births or other home-bound mobility limitations, or legal restrictions. Although multiple mechanisms may apply to the same population, supply-side barriers should be distinguished from demand-side barriers. Hard-to-vaccinate populations are defined as those who are reachable but difficult to vaccinate due to distrust, religious beliefs, lack of awareness of vaccine benefits and recommendations, poverty or low socioeconomic status, lack of time to access available vaccination services, or gender-based discrimination. Further work is needed to better define hard-to-reach populations and delineate them from populations that may be hard to vaccinate due to complex refusal reasons, improve measurement of the size and importance of their impact, and examine interventions related to overcoming barriers for each mechanism. This will enable policy makers, governments, donors, and the vaccine community to better plan interventions and allocate necessary resources to remove existing barriers to vaccination.

"Why Don't You Go Into Suburbs? Why Are You Targeting Us?": Trust and Mistrust in HIV Vaccine Trials in South Africa

Trust is a key element of high-quality stakeholder relations, which are themselves essential for the success of HIV vaccine trials. Where trust is absent, community stakeholders might not volunteer to become involved in key trial activities, and potential participants might not volunteer for enrollment. We explored site staff and Community Advisory Board (CAB) members’ experiences of trust/mistrust among community members and potential participants. We analyzed 10 focus group discussions with site staff and CAB members at two active South African HIV vaccine trial sites. We report on key characteristics perceived to contribute to the trustworthiness of communicators, as well as factors associated with mistrust. Attributes associated with trustworthy communicators included shared racial identity, competence, and independence (not being “captured”). Key foci for mistrust included explanations about site selection, stored samples, vaccination, and Vaccine Induced Sero-Positivity (VISP). Our findings suggest that community members’ trust is not necessarily global, in which trials are trusted or not; rather, it appears fairly nuanced and is impacted by various perceived attributes of communicators and the information they provide. We make recommendations for clinical trial site stakeholders invested in building trust and for future research into trust at these sites.

Variable Implementation of Sexuality Education in Three Nigerian States

In 2003, Nigeria adopted the Family Life and HIV Education (FLHE) sexuality education curriculum. Our analysis interrogates variation in sub-national implementation. We conducted 52 interviews with persons knowledgeable about the curriculum in three states-Kano, Lagos, and Niger-and reviewed publications on FLHE. In Kano, the socio-cultural context impeded implementation, but the persistence of innovative local champions resulted in some success. In Lagos, the cosmopolitan context, effective champions, funding by international donors, and a receptive government bureaucracy led to successful implementation. In Niger, despite a relatively conservative socio-cultural context, state bureaucratic bottlenecks overwhelmed proponents' efforts. In summary, the interaction of socio-cultural context, domestic champions, adaptive capacity of state bureaucracies, and international funders explains variable implementation of FLHE. The Nigerian experience highlights the need for sexuality education proponents to anticipate and prepare for local opposition and bureaucratic barriers.

Education is the antidote: Individual- and community-level effects of maternal education on child immunizations in Nigeria

Nigeria is an interesting case study because it outperforms other lower middle-income countries in economic development, yet ranks among the lowest in the world in immunization coverage rates. Combining multi-level modeling with spatial data techniques, this study investigates the individual- and community-level factors that influence the likelihood that a child is fully immunized, underscoring the importance of maternal education for improving child health. Drawing on data from the Demographic and Health Surveys and the Global Administrative Areas database, the analysis pools data on children aged 12-24 months across 455 communities. The spatial analysis reveals substantial geographic gaps in immunization coverage across Nigeria, demonstrating that not everyone benefits from the purported benefits of economic growth. Results from the multi-level models indicate that women's education has a robust association with vaccinations at the individual level and at the community level, even net of a variety of other household and community characteristics. The education level of a child's own mother influences the likelihood of being immunized, but above and beyond that, living in a community in which many women are educated also influences that likelihood. This suggests that education has a protective effect on child health not only because more individual women are going to school, but also because everyone benefits from the education and empowerment of women in the community. As broad societal transformations take place, education may shape women's capacity to take advantage of better access to power and resources, resulting in a dispersion effect of expanded women's education on health.

Threats to oral polio vaccine acceptance in Somalia: Polling in an outbreak

BACKGROUND

Using a survey conducted during the 2013-2014 polio outbreak in Somalia, this study examines attitudinal and knowledge-based threats to oral polio vaccine acceptance and commitment. Findings address a key gap, as most prior research focuses on endemic settings.

METHODS

Between November 19 and December 21, 2013, we conducted interviews among 2003 caregivers of children under 5 years in select districts at high risk for polio transmission. Within each district, sample was drawn via a multi-stage cluster design with random route household selection. We calculated the percentage of caregivers who could not confirm recent vaccination and those uncommitted to future vaccination. We compared these percentages among caregivers with varying knowledge and attitudes, focusing on variables identified as threats in endemic settings, using controlled and uncontrolled comparisons. We also examined absolute levels of threat variables.

RESULTS

Only 10% of caregivers could not confirm recent vaccination, but 32% were uncommitted to future vaccination. Being unvaccinated or uncommitted were related to multiple threat variables. For example, compared with relevant counterparts, caregivers were more likely to be unconfirmed and uncommitted if they did not trust vaccinators "a great deal" (unconfirmed: 9% vs. 2%; uncommitted: 49% vs. 28%), which is also true in endemic settings. Unlike endemic settings, symptom knowledge was related to commitment while rumor awareness was low and unrelated to past acceptance or commitment. Levels of trust and perceptions of OPV effectiveness were high, though perceptions of community support and awareness of logistics were lower.

CONCLUSIONS

As in endemic settings, outbreak responses will benefit from communications strategies focused on enhancing trust in vaccinators, institutions and the vaccine, alongside making community support visible. Disease facts may help motivate acceptance, and enhanced logistics information may help facilitate caregiver availability at the door. Quelling rumors early may be important to prevent them from becoming threats.

Awareness, perceptions and intent to comply with the prospective malaria vaccine in parts of South Eastern Nigeria

Background

There are potentials of a malaria vaccine being developed sooner than expected. While focus is more on the development of a vaccine, less attention has been paid on the extent to which such vaccines could be well accepted and the readiness among caregivers to comply with its use in order to achieve the effectiveness of the vaccine in the malaria endemic areas. Compliance rates are influenced by the level of awareness, as well as the perception of the population. This cross-sectional study was aimed at assessing the awareness, perceptions and intent to comply with the prospective malaria vaccine by caregivers in Owerri West, South Eastern Nigeria.

Methods

Structured pretested questionnaires were used to collect data from 500 randomly selected consenting care givers (mostly mothers). Items used to assess the intent to comply with the vaccine include willingness to accept and use the vaccine, and allow children to be vaccinated.

Results

The study found that awareness of malaria as a public health problem was high (89.8%), but awareness about a prospective malaria vaccine was not high (48.2%). Up to 88.2% of respondents showed positive perception towards the vaccine, of which 65.2% had strong positive perception. The study found high level of intent to comply with the prospective malaria vaccine among the study group (95.6% positive). Significant association was established between caregivers perception and intent to comply with the prospective malaria vaccine (χ² = 144.52; p < 0.0001).

Conclusions

While malaria vaccine adoption is likely to be a welcome development in South Eastern Nigeria, proper consideration should be given to factors that are likely to influence people’s perceptions about vaccines in the plans/process of malaria vaccine development and vaccination programmes.

HIV antiretroviral medication stock-outs in Ghana: contributors and consequences

Drug stock-outs are an unfortunate yet common reality for patients living in low and middle income countries, particularly in sub-Saharan Africa where trouble with consistent stock of antiretroviral medications (ARVs) continues. Our study takes a snapshot of this problem in Ghana. Although the country launched its antiretroviral therapy (ART) programme in 2003, progress toward realising the full benefit of ART for treated individuals has been limited, in part, because of stock-outs. In Ghana's Greater Accra region, we conducted semi-structured interviews with 40 women living with HIV (WLHIV) and 15 individuals with a history of HIV-related work in government or non-governmental organisations, or healthcare facilities. We used repeated review with coding and mapping techniques to analyse the transcripts and identify common themes. Stock-outs of ARVs result in inconsistent administration of therapy, increased indirect medical costs for WLHIV, and negative labelling of patients. Inefficiencies in drug supply, poor coordination with port authorities, inadequate government funding and dependence on international aid contribute to the stock-outs experienced in Ghana. Although using ARVs produced in-country could reduce supply problems, the domestically-manufactured product currently does not meet World Health Organization (WHO) standards. We recommend focused efforts to produce WHO standard ARVs in Ghana, and a review of current supply chain management to identify and mend pitfalls in the system.

A rapid qualitative assessment of oral cholera vaccine anticipated acceptability in a context of resistance towards cholera intervention in Nampula, Mozambique

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Political resistance impacts potential OCV acceptability.

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Perceived vulnerability to cholera overrides rationale for OCV hesitancy.

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Case-by-case preemptive studies maximize public health intervention acceptability.

Introduction

While planning an immunization campaign in settings where public health interventions are subject to politically motivated resistance, designing context-based social mobilization strategies is critical to ensure community acceptability. In preparation for an Oral Cholera Vaccine campaign implemented in Nampula, Mozambique, in November 2016, we assessed potential barriers and levers for vaccine acceptability.

Methods

Questionnaires, in-depth interviews, and focus group discussions, as well as observations, were conducted before the campaign. The participants included central and district level government informants (national immunization program, logistics officers, public health directors, and others), community leaders and representatives, and community members.

Results

During previous well chlorination interventions, some government representatives and health agents were attacked, because they were believed to be responsible for spreading cholera instead of purifying the wells. Politically motivated resistance to cholera interventions resurfaced when an OCV campaign was considered. Respondents also reported vaccine hesitancy related to experiences of problems during school-based vaccine introduction, rumors related to vaccine safety, and negative experiences following routine childhood immunization. Despite major suspicions associated with the OCV campaign, respondents’ perceived vulnerability to cholera and its perceived severity seem to override potential anticipated OCV vaccine hesitancy.

Discussion

Potential hesitancy towards the OCV campaign is grounded in global insecurity, social disequilibrium, and perceived institutional negligence, which reinforces a representation of estrangement from the central government, triggering suspicions on its intentions in implementing the OCV campaign. Recommendations include a strong involvement of community leaders, which is important for successful social mobilization; representatives of different political parties should be equally involved in social mobilization efforts, before and during campaigns; and public health officials should promote other planned interventions to mitigate the lack of trust associated with perceived institutional negligence. Successful past initiatives include public intake of purified water or newly introduced medication by social mobilizers, teachers or credible leaders.

Using best-worst scaling to rank factors affecting vaccination demand in northern Nigeria

BACKGROUND

Understanding and ranking the reasons for low vaccination uptake among parents in northern Nigeria is critical to implement effective policies to save lives and prevent illnesses. This study applies best-worst scaling (BWS) to rank various factors affecting parents' demand for routine childhood immunization.

METHODS

We conducted a household survey in Nahuche, Zamfara State in northern Nigeria. Nearly two hundred parents with children under age five were asked about their views on 16 factors using a BWS technique. These factors focused on known attributes that influence the demand for childhood immunization, which were identified from a literature review and reviewed by a local advisory board. The survey systematically presented parents with subsets of six factors and asked them to choose which they think are the most and least important in decisions to vaccinate children. We used a sequential best-worst analysis with conditional logistic regression to rank factors.

RESULTS

The perception that vaccinating a child makes one a good parent was the most important motivation for parents in northern Nigeria to vaccinate children. Statements related to trust and social norms were ranked higher in importance compared to those that highlighted perceived benefits and risks, healthcare service, vaccine information, or opportunity costs. Fathers ranked trust in the media and views of their leaders to be of greatest importance, whereas mothers placed greater importance on social perceptions and norms. Parents of children without routine immunization ranked their trust in local leaders about vaccines higher in considerations, and the media's views lower, compared to parents with children who received routine immunization.

CONCLUSIONS

Framing immunization messages in the context of good parenting and hearing these messages from trusted information sources may motivate parental uptake of childhood vaccines. These results are useful to policymakers to prioritize resources in order to increase awareness and demand for childhood immunization.

Polio elimination in Nigeria: A review

Nigeria has made tremendous strides towards eliminating polio and has been free of wild polio virus (WPV) for more than a year as of August 2015. However, sustained focus towards getting rid of all types of poliovirus by improving population immunity and enhancing disease surveillance will be needed to ensure it sustains the polio-free status. We reviewed the pertinent literature including published and unpublished, official reports and working documents of the Global Polio Eradication Initiative (GPEI) partners as well as other concerned organizations. The literature were selected based on the following criteria: published in English Language, published after year 2000, relevant content and conformance to the theme of the review and these were sorted accordingly. The challenges facing the Polio Eradication Initiative (PEI) in Nigeria were found to fall into 3 broad categories viz failure to vaccinate, failure of the Oral Polio Vaccine (OPV) and epidemiology of the virus. Failure to vaccinate resulted from insecurity, heterogeneous political support, programmatic limitation in implementation of vaccination campaigns, poor performance of vaccination teams in persistently poor performing Local Government areas and sporadic vaccine refusals in Northern Nigeria. Sub optimal effectiveness of OPV in some settings as well as the rare occurrence of VDPVs associated with OPV type 2 in areas of low immunization coverage were also found to be key issues. Some of the innovations which helped to manage the threats to the PEI include a strong government accountability frame work, change from type 2 containing OPV to bi valent OPVs for supplementary immunization activities (SIA), enhancing environmental surveillance in key states (Sokoto, Kano and Borno) along with an overall improvement in SIA quality. There has been an improvement in coverage of routine immunization and vaccination campaigns, which has resulted in Nigeria being removed from the list of endemic countries following an absence of new cases for an entire year as of September 2015. However, the last mile remains to be crossed and there is need to further improve and sustain the momentum to complete the journey toward polio elimination.

Parents' and informal caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence

BACKGROUND

Childhood vaccination is an effective way to prevent serious childhood illnesses, but many children do not receive all the recommended vaccines. There are various reasons for this; some parents lack access because of poor quality health services, long distances or lack of money. Other parents may not trust vaccines or the healthcare workers who provide them, or they may not see the need for vaccination due to a lack of information or misinformation about how vaccinations work and the diseases they can prevent.Communication with parents about childhood vaccinations is one way of addressing these issues. Communication can take place at healthcare facilities, at home or in the community. Communication can be two-way, for example face-to-face discussions between parents and healthcare providers, or one-way, for instance via text messages, posters or radio programmes. Some types of communication enable parents to actively discuss vaccines and their benefits and harms, as well as diseases they can prevent. Other communication types simply give information about vaccination issues or when and where vaccines are available. People involved in vaccine programmes need to understand how parents experience different types of communication about vaccination and how this influences their decision to vaccinate.

OBJECTIVES

The specific objectives of the review were to identify, appraise and synthesise qualitative studies exploring: parents' and informal caregivers' views and experiences regarding communication about childhood vaccinations and the manner in which it is communicated; and the influence that vaccination communication has on parents' and informal caregivers' decisions regarding childhood vaccination.

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-process and Other Non-Index Citations (Ovid SP), Embase (Ovid), CINAHL (EbscoHOST), and Anthropology Plus (EbscoHost) databases for eligible studies from inception to 30 August 2016. We developed search strategies for each database, using guidelines developed by the Cochrane Qualitative Research Methods Group for searching for qualitative evidence as well as modified versions of the search developed for three related reviews of effectiveness. There were no date or geographic restrictions for the search.

SELECTION CRITERIA

We included studies that utilised qualitative methods for data collection and analysis; focused on the views and experiences of parents and informal caregivers regarding information about vaccination for children aged up to six years; and were from any setting globally where information about childhood vaccinations was communicated or distributed.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, using a three-step sampling frame. We conducted a thematic analysis using a constant comparison strategy for data extraction and synthesis. We assessed our confidence in the findings using the GRADE-CERQual approach. High confidence suggests that it is highly likely that the review finding is a reasonable representation of the phenomenon of interest, while very low confidence indicates that it is not clear whether the review finding is a reasonable representation of it. Using a matrix model, we then integrated our findings with those from other Cochrane reviews that assessed the effects of different communication strategies on parents' knowledge, attitudes and behaviour about childhood vaccination.

MAIN RESULTS

We included 38 studies, mostly from high-income countries, many of which explored mothers' perceptions of vaccine communication. Some focused on the MMR (measles, mumps, rubella) vaccine.In general, parents wanted more information than they were getting (high confidence in the evidence). Lack of information led to worry and regret about vaccination decisions among some parents (moderate confidence).Parents wanted balanced information about vaccination benefits and harms (high confidence), presented clearly and simply (moderate confidence) and tailored to their situation (low confidence in the evidence). Parents wanted vaccination information to be available at a wider variety of locations, including outside health services (low confidence) and in good time before each vaccination appointment (moderate confidence).Parents viewed health workers as an important source of information and had specific expectations of their interactions with them (high confidence). Poor communication and negative relationships with health workers sometimes impacted on vaccination decisions (moderate confidence).Parents generally found it difficult to know which vaccination information source to trust and challenging to find information they felt was unbiased and balanced (high confidence).The amount of information parents wanted and the sources they felt could be trusted appeared to be linked to acceptance of vaccination, with parents who were more hesitant wanting more information (low to moderate confidence).Our synthesis and comparison of the qualitative evidence shows that most of the trial interventions addressed at least one or two key aspects of communication, including the provision of information prior to the vaccination appointment and tailoring information to parents' needs. None of the interventions appeared to respond to negative media stories or address parental perceptions of health worker motives.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several review findings. Further research, especially in rural and low- to middle-income country settings, could strengthen evidence for the findings where we had low or very low confidence. Planners should consider the timing for making vaccination information available to parents, the settings where information is available, the provision of impartial and clear information tailored to parental needs, and parents' perceptions of health workers and the information provided.

Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia

Trust in government has long been viewed as an important determinant of citizens' compliance with public health policies, especially in times of crisis. Yet evidence on this relationship remains scarce, particularly in the developing world. We use results from a representative survey conducted during the 2014-15 Ebola Virus Disease (EVD) epidemic in Monrovia, Liberia to assess the relationship between trust in government and compliance with EVD control interventions. We find that respondents who expressed low trust in government were much less likely to take precautions against EVD in their homes, or to abide by government-mandated social distancing mechanisms designed to contain the spread of the virus. They were also much less likely to support potentially contentious control policies, such as "safe burial" of EVD-infected bodies. Contrary to stereotypes, we find no evidence that respondents who distrusted government were any more or less likely to understand EVD's symptoms and transmission pathways. While only correlational, these results suggest that respondents who refused to comply may have done so not because they failed to understand how EVD is transmitted, but rather because they did not trust the capacity or integrity of government institutions to recommend precautions and implement policies to slow EVD's spread. We also find that respondents who experienced hardships during the epidemic expressed less trust in government than those who did not, suggesting the possibility of a vicious cycle between distrust, non-compliance, hardships and further distrust. Finally, we find that respondents who trusted international non-governmental organizations (INGOs) were no more or less likely to support or comply with EVD control policies, suggesting that while INGOs can contribute in indispensable ways to crisis response, they cannot substitute for government institutions in the eyes of citizens. We conclude by discussing the implications of our findings for future public health crises.

Ambiguous Capture: Collaborative Capitalism and the Meningitis Vaccine Project

The primary health care approach advanced at Alma Ata to address social determinants of health was replaced by selective health care a year later at Bellagio. Subsequently, immunization was endorsed as a cost-effective technical intervention to combat targeted infectious diseases. Multilateral efforts to collaborate on immunization as a universal public health good ambiguously capture the interests of the world's governments as well as private, public, and not-for-profit institutions. Global assemblages of scientists, governments, industry and nongovernmental organizations now work in public-private partnerships to develop and make essential vaccines accessible, with vaccines marketed as single fix solutions for global health. Drawing from ethnographic fieldwork in France and Burkina Faso that followed the development, regulation, and implementation of the group A meningococcal conjugate vaccine for sub-Saharan Africa, in this article I describe events during and after the development of MenAfriVac. A technological success narrative steeped in collaborative capitalist rhetoric disguises neglected health care systems.

Towards people-centred health systems: a multi-level framework for analysing primary health care governance in low- and middle-income countries

Although there is evidence that non-government health system actors can individually or collectively develop practical strategies to address primary health care (PHC) challenges in the community, existing frameworks for analysing health system governance largely focus on the role of governments, and do not sufficiently account for the broad range of contribution to PHC governance. This is important because of the tendency for weak governments in low- and middle-income countries (LMICs). We present a multi-level governance framework for use as a thinking guide in analysing PHC governance in LMICs. This framework has previously been used to analyse the governance of common-pool resources such as community fisheries and irrigation systems. We apply the framework to PHC because, like common-pool resources, PHC facilities in LMICs tend to be commonly owned by the community such that individual and collective action is often required to avoid the ‘tragedy of the commons’—destruction and degradation of the resource resulting from lack of concern for its continuous supply. In the multi-level framework, PHC governance is conceptualized at three levels, depending on who influences the supply and demand of PHC services in a community and how: operational governance (individuals and providers within the local health market), collective governance (community coalitions) and constitutional governance (governments at different levels and other distant but influential actors). Using the example of PHC governance in Nigeria, we illustrate how the multi-level governance framework offers a people-centred lens on the governance of PHC in LMICs, with a focus on relations among health system actors within and between levels of governance. We demonstrate the potential impact of health system actors functioning at different levels of governance on PHC delivery, and how governance failure at one level can be assuaged by governance at another level.

Eradication and Current Status of Poliomyelitis in Pakistan: Ground Realities

Pakistan is among the last three countries along with Afghanistan and Nigeria, where polio virus is still endemic. More or less, with some fluctuations, numbers of reported cases in the past few years have shown a rising trend. Year 2014 pushed the country into the deep sea of difficulties, as number of cases rose to red alert level of 328. Security situation has adversely affected the whole immunization coverage campaign. In a country where 40 polio vaccinators have been killed since 2012, such a big number of cases is not a surprising outcome. Worse perception of parents about polio vaccine as in Karachi and FATA, the high risk zones, makes 100% coverage a dream. Minor and perhaps delayed payments to polio workers make them frustrated, resulting in decline of trained manpower for vaccination. Strong implementation of policies is required and those found guilty of attack on polio workers need to be punished. Targeted community awareness programme, strong surveillance network, and involvement of influential religious entities can help to root out polio disease from country. Present review is aimed at analyzing all barriers on the road to success in eradication of polio from Pakistan.

Polio infrastructure strengthened disease outbreak preparedness and response in the WHO African Region

INTRODUCTION

The continuous deployments of polio resources, infrastructures and systems for responding to other disease outbreaks in many African countries has led to a number of lessons considered as best practice that need to be documented for strengthening preparedness and response activities in future outbreaks.

METHODS

We reviewed and documented the influence of polio best practices in outbreak preparedness and response in Angola, Nigeria and Ethiopia. Data from relevant programmes of the WHO African Region were also analyzed to demonstrate clearly the relative contributions of PEI resources and infrastructure to effective disease outbreak preparedness and response.

RESULTS

Polio resources including, human, financial, and logistic, tool and strategies have tremendously contributed to responding to diseases outbreaks across the African region. In Angola, Nigeria and Ethiopia, many disease epidemics including Marburg Hemorrhagic fever, Dengue fever, Ebola Virus Diseases (EVD), Measles, Anthrax and Shigella have been controlled using existing polio Eradication Initiatives resources. Polio staffs are usually deployed in occasions to supports outbreak response activities (coordination, surveillance, contact tracing, case investigation, finance, data management, etc.). Polio logistics such vehicles, laboratories were also used in the response activities to other infectious diseases. Many polio tools including micro planning, dashboard, guidelines, SOPs on preparedness and response have also benefited to other epidemic-prone diseases. The Countries' preparedness and response plan to WPV importation as well as the Polio Emergency Operation Center models were successfully used to develop, strengthen and respond to many other diseases outbreak with the implication of partners and the strong leadership and ownership of governments. This review has important implications for WHO/AFRO initiative to strengthening and improving disease outbreak preparedness and responses in the African Region in respect to the international health regulations core capacities.

Explaining socio-economic inequalities in immunization coverage in Nigeria

Globally, in 2013 over 6 million children younger than 5 years died from either an infectious cause or during the neonatal period. A large proportion of these deaths occurred in developing countries, especially in sub-Saharan Africa. Immunization is one way to reduce childhood morbidity and deaths. In Nigeria, however, although immunization is provided without a charge at public facilities, coverage remains low and deaths from vaccine preventable diseases are high. This article seeks to assess inequalities in full and partial immunization coverage in Nigeria. It also assesses inequality in the 'intensity' of immunization coverage and it explains the factors that account for disparities in child immunization coverage in the country. Using nationally representative data, this article shows that disparities exist in the coverage of immunization to the advantage of the rich. Also, factors such as mother's literacy, region and location of the child, and socio-economic status explain the disparities in immunization coverage in Nigeria. Apart from addressing these issues, the article notes the importance of addressing other social determinants of health to reduce the disparities in immunization coverage in the country. These should be in line with the social values of communities so as to ensure acceptability and compliance. We argue that any policy that addresses these issues will likely reduce disparities in immunization coverage and put Nigeria on the road to sustainable development.

Role of Serial Polio Seroprevalence Studies in Guiding Implementation of the Polio Eradication Initiative in Kano, Nigeria: 2011-2014

BACKGROUND

Nigeria was one of 3 polio-endemic countries before it was de-listed in September 2015 by the World Health Organization, following interruption of transmission of the poliovirus. During 2011-2014, Nigeria conducted serial polio seroprevalence surveys (SPS) in Kano Metropolitan Area, comprising 8 local government areas (LGAs) in Kano that is considered very high risk (VHR) for polio, to monitor performance of the polio eradication program and guide the program in the adoption of innovative strategies.

METHODS

Study subjects who resided in any of the 8 local government areas of Kano Metropolitan Area and satisfied age criteria were recruited from patients at Murtala Mohammed Specialist Hospital (Kano) for 3 seroprevalence surveys. The same methods were used to conduct each survey.

RESULTS

The 2011 study showed seroprevalence values of 81%, 75%, and 73% for poliovirus types 1, 2, and 3, respectively, among infants aged 6-9 months age. Among children aged 36-47 months, seroprevalence values were greater (91%, 87%, and 85% for poliovirus types 1, 2, and 3, respectively).In 2013, the results showed that the seroprevalence was unexpectedly low among infants aged 6-9 months, remained high among children aged 36-47 months, and increased minimally among children aged 5-9 years and those aged 10-14 years. The baseline seroprevalence among infants aged 6-9 months in 2014 was better than that in 2013.

CONCLUSIONS

The results from the polio seroprevalence surveys conducted in Kano Metropolitan Area in 2011, 2013, and 2014 served to assess the trends in immunity and program performance, as well as to guide the program, leading to various interventions being implemented with good effect, as evidenced by the reduction of poliovirus circulation in Kano.

Demand Creation for Polio Vaccine in Persistently Poor-Performing Communities of Northern Nigeria: 2013-2014

Introduction. Poliomyelitis remains a global threat despite availability of oral polio vaccine (OPV), proven to reduce the burden of the paralyzing disease. In Nigeria, children continue to miss the opportunity to be fully vaccinated, owing to factors such as unmet health needs and low uptake in security-compromised and underserved communities. We describe the implementation and evaluation of several activities to create demand for polio vaccination in persistently poor-performing local government areas (LGAs).

Methods. We assessed the impact of various polio-related interventions, to measure the contribution of demand creation activities in 77 LGAs at very high risk for polio, located across 10 states in northern Nigeria. Interventions included provision of commodities along with the polio vaccine.

Results. There was an increasing trend in the number of children reached by different demand creation interventions. A total of 4 819 847 children were vaccinated at health camps alone. There was a reduction in the number of wards in which >10% of children were missed by supplementary immunization activities due to noncompliance with vaccination recommendations, a rise in the proportion of children who received ≥4 OPV doses, and a decrease in the proportion of children who were underimmunized or unimmunized.

Conclusions. Demand creation interventions increased the uptake of polio vaccines in persistently poor-performing high-risk communities in northern Nigeria during September 2013–November 2014.

The Journalists Initiatives on Immunisation Against Polio and Improved Acceptance of the Polio Vaccine in Northern Nigeria 2007-2015

BACKGROUND

The polio eradication initiative had major setbacks in 2003 and 2007 due to media campaigns in which renowned scholars and Islamic clerics criticized polio vaccines. The World Health Organization (WHO) partnered with journalists in 2007 to form the Journalists Initiatives on Immunisation Against Polio (JAP), to develop communication initiatives aimed at highlighting polio eradication activities and the importance of immunization in northern Nigeria.

METHODS

We evaluated the impact of JAP activities in Kaduna State by determining the total number of media materials produced and the number of newspaper clips and bulletins published in support of polio eradication. We also determined the number of households in noncompliant communities that became compliant with vaccination during 2015 supplementary immunization activities (SIAs) after JAP interventions and compared caregivers' sources of information about SIAs in 2007 before and after the JAP was formed.

RESULTS

Since creation of the JAP, >500 reports have been published and aired, with most portraying polio vaccine positively. During June 2015 SIAs in high-risk wards of Kaduna STATE, JAP interventions resulted in vaccination of 5122 of 5991 children (85.5%) from noncompliant households. During early 2007, the number of caregivers who had heard about SIA rounds from the media increased from 26% in January, before the JAP was formed, to 33% in March, after the initiation of JAP activities.

CONCLUSIONS

The formation of the JAP resulted in measurable improvement in the acceptance of polio vaccine in northern Nigeria.

Mass immunization with inactivated polio vaccine in conflict zones--Experience from Borno and Yobe States, North-Eastern Nigeria

The use of Inactivated Polio Vaccine (IPV) in routine immunization to replace Oral Polio Vaccine (OPV) is crucial in eradicating polio. In June 2014, Nigeria launched an IPV campaign in the conflict-affected states of Borno and Yobe, the largest ever implemented in Africa. We present the initiatives and lessons learned. The 8-day event involved two parallel campaigns. OPV target age was 0-59 months, while IPV targeted all children aged 14 weeks to 59 months. The Borno state primary health care agency set up temporary health camps for the exercise and treated minor ailments for all. The target population for the OPV campaign was 685,674 children in Borno and 113,774 in Yobe. The IPV target population for Borno was 608,964 and for Yobe 111,570. OPV coverage was 105.1 per cent for Borno and 103.3 per cent for Yobe. IPV coverage was 102.9 per cent for Borno and 99.1 per cent for Yobe. (Where we describe coverage as greater than 100 per cent, this reflects original underestimates of the target populations.) A successful campaign and IPV immunization is viable in conflict areas.

Gender Determinants of Vaccination Status in Children: Evidence from a Meta-Ethnographic Systematic Review

Using meta-ethnographic methods, we conducted a systematic review of qualitative research to understand gender-related reasons at individual, family, community and health facility levels why millions of children in low and middle income countries are still not reached by routine vaccination programmes. A systematic search of Medline, Embase, CINAHL, Cochrane Library, ERIC, Anthropological Lit, CSA databases, IBSS, ISI Web of Knowledge, JSTOR, Soc Index and Sociological Abstracts was conducted. Key words were built around the themes of immunization, vaccines, health services, health behaviour, and developing countries. Only papers, which reported on in-depth qualitative data, were retained. Twenty-five qualitative studies, which investigated barriers to routine immunisation, were included in the review. These studies were conducted between 1982 and 2012; eighteen were published after 2000. The studies represent a wide range of low- to middle income countries including some that have well known coverage challenges. We found that women's low social status manifests on every level as a barrier to accessing vaccinations: access to education, income, as well as autonomous decision-making about time and resource allocation were evident barriers. Indirectly, women's lower status made them vulnerable to blame and shame in case of childhood illness, partly reinforcing access problems, but partly increasing women's motivation to use every means to keep their children healthy. Yet in settings where gender discrimination exists most strongly, increasing availability and information may not be enough to reach the under immunised. Programmes must actively be designed to include mitigation measures to facilitate women's access to immunisation services if we hope to improve immunisation coverage. Gender inequality needs to be addressed on structural, community and household levels if the number of unvaccinated children is to substantially decrease.

Threats to polio eradication in high-conflict areas in Pakistan and Nigeria: a polling study of caregivers of children younger than 5 years

BACKGROUND

Elimination of poliovirus from endemic countries is a crucial step in eradication; however, vaccination programmes in these areas face challenges, especially in regions with conflict. We analysed interviews with caregivers of children living in two polio-endemic countries to assess whether these challenges are largely operational or also driven by resistance or misinformation in the community.

METHODS

We designed and analysed polls based on face-to-face interviews of a random sample of parents and other caregivers of children younger than 5 years in regions of Pakistan and Nigeria at high risk for polio transmission. In both countries, the sample was drawn via a stratified multistage cluster design with random route household selection. The questionnaire covered awareness, knowledge, and attitudes about polio and oral polio vaccine (OPV), trust in vaccination efforts, and caregiver priorities for government action. We assessed experiences of caregivers in accessible higher-conflict areas and compared their knowledge and attitudes with those in lower-conflict areas. Differences were tested with two-sample t tests.

FINDINGS

The poll consisted of 3396 caregivers from Pakistan and 2629 from Nigeria. About a third of caregivers who responded in higher-conflict areas of Pakistan (Federally Administered Tribal Areas [FATA], 30%) and Nigeria (Borno, 33%) were unable to confirm that their child was vaccinated in the previous campaign. In FATA, 12% of caregivers reported that they were unaware of polio, and in Borno 12% of caregivers reported that vaccinators visited but their child did not receive the vaccine or they did not know whether the child was vaccinated. Additionally, caregivers in higher-conflict areas are less likely to hold beliefs about OPV that could motivate acceptance and are more likely to hold concerns than are caregivers in lower-conflict areas.

INTERPRETATION

Beyond the difficulties in reaching homes with OPV, challenges for vaccination programmes in higher-conflict areas extend to limited awareness, negative attitudes, and gaps in trust. Vaccination efforts might need to address underlying attitudes of caregivers through direct communications and the selection and training of local vaccinators.

FUNDING

Harvard T H Chan School of Public Health and UNICEF.