Collaborating with communities to improve vaccine coverage: a strategy worth pursuing?
It is unfortunate but distrust of vaccines remains widespread in the world today. In August 2003, a polio vaccination boycott was declared in the five northern states of Nigeria. Political and religious leaders argued that the vaccines could be contaminated with anti-fertility agents, HIV and cancer-causing agents. It took a full year to resolve the boycott but the one year period wreaked havoc on the status of polio across the world. There were polio outbreaks in three continents during that one year period. It ended up costing public health officials more than US$500. This distrust also continues in Afghanistan and Pakistan today.
It is clear that confidence in vaccinations is not just an individual phenomenon but is very much a social phenomenon. Indeed the negative consequences of low vaccine uptake in terms of public health are very large.
Social factors play a very significant role in creating this distrust and affecting vaccine uptake (See here and here for more on factors affecting uptake). Confidence in vaccine efficacy (‘The vaccine will be harmful to us!’) is only one reason affecting uptake. Other reasons include complacency (‘Of course it won’t happen to me!’; ‘It has never happened in our family!’) and convenience (‘The clinic is just too far away’; ‘It is too expensive’). The public good nature of getting vaccinated is also important to note – unvaccinated people are likely to get infected and infect other unvaccinated people. Vaccinated people on the other hand don’t get infected and the cycle breaks.
To change these attitudes towards vaccines, communities rather than individuals, can and should play a big role in in collectively ensuring that a significant proportion of the population gets vaccinated.
In a new 3ie scoping paper, we along with our co-authors discuss the important role that communities can play in not just encouraging demand within communities to take up vaccines and dispel mistrust but also in co-managing and co-delivering immunisation programmes in general. Communities can help implementing organisations plan deliveries of vaccines as well as set up schedules and monitor uptake. Our systematically collected evidence (we include a gap map of evidence on this subject) shows that co-management and co-delivery that actively involve communities in project design, implementation, monitoring and evaluation can be a significant factor in achieving success in increasing vaccine coverage.
Our main findings from the scoping study are:
- Community engagement is under-used in creating and sustaining demand for immunisation as well as in planning and ensuring the delivery of vaccines.
- Even if communities are engaged and demand is created, the supply side is almost as important. Organisations need to be cognizant that implementation and service delivery are likely to be a constraint. Communities may be sensitised and involved in ensuring good quality delivery and implementation in various ways. Importantly, if supply-side constraints are not dealt with, the lack of confidence in vaccines is likely to get aggravated.
- More evidence is required to show how co-delivery and co-management might be organised and ensured. We also need to do more work to understand for which specific types of populations this may be most effective.
- Not surprisingly, the cultural context within which vaccines are being delivered and the kinds of communities being engaged with is extremely critical.
- We conclude that one way in which some of these constraints may also be dealt with, is through the use of technology, especially technologies that help to plan and monitor better. But evidence is needed about what works and what does not in using technology for engaging communities to help increase coverage, uptake and ensuring supply.
It is to fill this evidence gap that 3ie, with the support of the Bill & Melinda Gates Foundation, has launched an evidence programme that will generate new evidence about what works to engage communities in increasing immunisation coverage, test the feasibility and effectiveness of these approaches and inform their scale up. Watch this space for what we learn as we go along.
Watch: Shagun Sabarwal, Evaluation Specialist at 3ie, talk about the main findings of this scoping paper in this short video.