The Critical Public Health Value of Vaccines Tackling Issues of Access and Hesitancy: Proceedings of a Workshop (2021) / Chapter Skim
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4 Assessing Global and Local Drivers of Vaccine Hesitancy
4 Assessing Global and Local Drivers of Vaccine Hesitancy
Pages 57-84
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From page 57... ...
Stefan Flasche, associate professor at the London School of Hygiene & Tropical Medicine, described the burden of vaccine-attributable severe dengue in the Philippines and the effect of dengue vaccination campaigns on the national immunization program. Julie Leask, professor at the University of Sydney, Australia, discussed measurements of behavior and social drivers of vaccination.
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From page 58... ...
vaccination efforts based on lessons learned from this case study in the Philippines. Dengue and Dengvaxia Dengue is a major global health priority, with 100–400 million annual infections worldwide.1 Flasche said that many people with dengue require medical attention, with some developing severe symptoms including death (though this is relatively rare)
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From page 59... ...
Yet the potential safety signal was only observed in children aged 2–5 years and was not observed during the trial in any participant aged 9 years or older. Flasche added that modeling suggested that even in dengue-naïve vaccine recipients, the lifetime net effect would be potentially positive despite the possibility of bringing forward risk (Ferguson et al., 2016)
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From page 60... ...
Although there was the potential for a similarly negative public response in Brazil, the announcement largely went unnoticed and controversy around Dengvaxia only took place in the Philippines. Impact on the National Immunization Program The fallout from the Dengvaxia vaccination campaign had a substantial negative impact on the national immunization program in the Philippines,
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From page 61... ...
Additionally, vaccination rates dropped in the national immunization program and particularly in the childhood program. For example, it took many years to achieve a relatively high level (88 percent)
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From page 62... ...
The BeSD working group was formed to develop globally standardized tools to measure core components of the Increasing Vaccination Model, including people's thoughts and feelings, social processes, motivation, and practical issues regarding vaccination. She also explored the rationale for developing new tools to understand the vaccination gap of approximately 20 million children worldwide.
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From page 63... ...
Additionally, Leask noted that the binary notion of supply and demand oversimplifies the ways in which barriers to uptake are conceptualized, and that findings from the data already collected often go unused. New Tools to Measure and Address Behavioral and Social Drivers of Vaccination Leask emphasized that new measures are needed to understand the vaccination gap and its causes.
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From page 64... ...
Leask explained that people's thoughts and feelings about vaccination include confidence in vaccine benefits, vaccine safety, and in the provider, as well as religious beliefs. Social processes include the social influences of the provider, family, and community, in addition to gender equity and the decision-making autonomy that a woman in the family has.
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From page 65... ...
" The in-depth interview states, "Walk me through what you do on the day of vaccination; start at the very beginning." Field Testing the Increasing Vaccination Model Leask said that these new tools are being field tested in countries like Sierra Leone, where the BeSD working group partnered with Statistics Sierra Leone to integrate the tools into preparation for a national survey.8 This involved cognitive interviews in which researchers studied how people interpret the survey questions to ensure that the questions are phrased in a way they can be understood as intended. This process includes asking participants a question, then asking them questions about the question.
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From page 66... ...
. 13 Results from the 2017 Childhood National Immunization Coverage Survey conducted by Health Canada can be found at https://www.canada.ca/en/public-health/services/publications/ healthy-living/2017-vaccine-uptake-canadian-children-survey.html (accessed February 25, 2021)
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From page 67... ...
This illustrates how lack of uniform data measurements can make it challenging to identify areas of low vaccine coverage on a global scale. Bettinger reported that the United States and Canada had similar rates of influenza vaccination from 2018–2019 (PHAC, 2019)
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From page 68... ...
. Continuum of Vaccine Acceptance Model Bettinger emphasized that vaccine coverage, non-coverage, and exemption rates are important, but "they do not tell the whole story." These data allow experts to focus attention on particular vaccines, age groups, jurisdictions, and other demographics (e.g., the uninsured)
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From page 69... ...
Many of these individuals have had negative experiences with health care providers, the medical system, or vaccines. She noted that in some cases, these negative experiences have nothing to do with vaccines but were powerful enough to make people distrustful of any advice from health care providers.
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From page 70... ...
He described the relative effect of different types of interventions based on those propositions and suggested ways forward to apply the model toward influencing vaccination behavior. In collaboration with Julie Leask, Gretchen Chapman, Alex Rothman, and Allie Kempe, Brewer developed the Increasing Vaccination Model to help address low vaccination uptake (Brewer et al., 2017a)
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From page 71... ...
Proposition 2: Social Processes Influence Vaccination Behavior The second proposition of the Increasing Vaccination Model is that social processes influence vaccination. Brewer explained that social processes begin with an individual's virtual or in-person social network (e.g., family, friends, colleagues, neighbors)
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From page 72... ...
For instance, presumptive health care provider recommendations, onsite vaccination, default appointments, incentives, and vaccination requirements all show a substantial likely impact. Reminders and callbacks showed a modest effect, which Brewer surmised would be greater if provided consistently with appropriate follow-through in primary care.
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From page 73... ...
At the end of the intervention, 6 percent of 18-month-olds in the control group were fully vaccinated, compared with 18 percent in the monthly vaccination camp; the rate increased to 39 percent in the villages that provided monthly vaccination camps with incentives. Ways to Apply the Model to Influence Vaccination Behavior Based on his review of this data, Brewer said that the proposition that people's thoughts and feelings affect vaccination behavior is not as promising in trying to improve vaccine uptake.
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From page 74... ...
controlling seasonal influenza rates may help avoid dual global pandemics. He suggested that when a vaccine for COVID19 becomes available, tools to increase vaccine uptake should be used within programs built on strong logistics and based on concretely effective strategies, rather than focusing exclusively on media campaigns.
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From page 75... ...
Although the ways people think and feel about vaccines are an important part of the mechanism, and communicating about vaccination is important, she contended that such interventions alone are not sufficient to substantially improve vaccine coverage. Bettinger agreed that a focus on structural interventions such as mandates and incentives (which are more common in the United States and Australia than in Canada)
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From page 76... ...
Recommendations for COVID-19 Vaccine Acceptance Buttenheim asked about first-priority strategies to increase acceptance of the upcoming COVID-19 vaccine. Flasche reiterated that a provider recommendation is potentially the biggest factor influencing a person's likelihood of getting vaccinated; therefore, strong recommendations from providers could have the largest possible impact.
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From page 77... ...
Brewer noted the complexities involved in understanding why different ethnic groups have higher or lower vaccine coverage. For instance, African American adults are less likely to get the influenza vaccine than white adults, yet African American families are more likely to get the first dose of HPV vaccine for their children than their white counterparts.
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From page 78... ...
With respect to people experiencing homelessness, Leask suggested working to increase vaccine uptake by leveraging 20 More information on vaccine coverage in Australian Aboriginal and Torres Strait Islander peoples is available at https://www.health.gov.au/health-topics/immunisation/childhoodimmunisation-coverage/immunisation-coverage-rates-for-aboriginal-and-torres-straitislander-children (accessed May 20, 2021) and https://www.health.gov.au/health-topics/ immunisation/childhood-immunisation-coverage/immunisation-coverage-rates-for-all-children (accessed December 18, 2020)
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From page 79... ...
. 22 WHO's guidance on how to respond to vocal vaccine deniers in public is available at https://www.who.int/immunization/sage/meetings/2016/october/8_Best-practice-guidancerespond-vocal-vaccine-deniers-public.pdf (accessed November 10, 2020)
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From page 80... ...
Bettinger responded that both are substantial challenges, but the extent to which each contributes separately to vaccine coverage issues is unclear. An additional challenge in Canada is that the seasonal influenza vaccine is not universally covered in all provinces and territories, which further complicates efforts to measure the drivers of low coverage.
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From page 81... ...
Having spent years working on improving seasonal influenza vaccination rates in children and adults, Leask said she hopes that a COVID-19 vaccine will lead to lasting improvement in seasonal influenza vaccination rates. She predicted that communities and governments will likely be motivated to have high vaccination coverage in order to return to pre-pandemic life.
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From page 82... ...
Orenstein remarked, "Vaccines do not save lives; vaccinations save lives." He contended that substantial resources are needed not only for vaccine development research, but also for vaccine implementation research. Zahn noted that the dengue vaccine controversy in the Philippines illustrates the value of accurate messaging and providing the public with information on the front end to help families understand the risks of vaccines and shape public perceptions toward vaccine uptake.
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From page 83... ...
Given the crucial role of provider recommendations in influencing people to get vaccinated, Zahn underscored the need for providers to communicate a clear and consistent message to their patients. Orenstein said that direct sources of immunization information may be useful, but most studies have shown that primary care providers are often the most trusted source for vaccination information.
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