December 16, 2024 • 26 mins
This year marks the 50th anniversary of the Expanded Programme of Immunization (EPI), a global initiative to get vaccines to every child, everywhere. While much progress has been made over the last 50 years, there is still much more work to be done to ensure equitable access to vaccines for all.
In this episode, Qali speaks with immunisation experts to understand what Social and Behaviour Change (SBC) can bring to the challenge of reaching everyone and navigating vaccination in a world still recovering from the impacts of COVID-19.
Guests (in order of appearance)
- Francine Ganter Restrepo, SBC Specialist, Immunisation and Health, UNICEF East and Southern Africa Regional Office (ESARO)
- Heidi Larson, Founder and Director of The Vaccine Confidence Project
- Dr. Saad Omer, Dean, Peter O’Donnell Jr. School of Public Health
Resources (in order of mention)
- Global immunization efforts have saved at least 154 million lives over the past 50 years, UNICEF Armenia
- NYHQ ED Russell World Immunization Week 2024
- 50th Anniversary of the Expanded Programme on Immunization
- Finding the missing link: Improving vaccination coverage in zero dose communities with human-centred design, UNICEF
- Humanly Possible: Immunization for all, UNICEF
- SBC in Support of System Strengthening
The views and opinions expressed by the contributors are their own and do not necessarily reflect the views or positions of UNICEF or any entities they represent. The content here is for information purposes only.
The ABCs of SBC is hosted by Qali Id and produced and developed by Helena Ballester Bon in partnership with Common Thread.
Check out UNICEF’s latest publication on Social and Behaviour Change, Why don’t you just behave! For more information about UNICEF SBC, check out the programme guidance.
We care about what you think — you can share your thoughts on the podcast using this feedback form. For all other inquiries, please contact sbc@unicef.org.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Qali Id (00:02):
What is one intervention that has saved
six lives every minute,8, 000 lives every day
over the last 50 years?
Any guesses?
It starts with an I, endswith an N, and I promise
it's not just a productof our imagination.
Welcome back to the ABCs of SBC.
(00:27):
In this episode, we'll bediscussing immunization.
We've come a very long waysince the first vaccine.
The smallpox vaccine,which was invented in 1796.
This was a major breakthrough,kickstarting the development of
numerous life saving vaccinesand ultimately led to the global
eradication of smallpox in 1980.
(00:48):
But we still havea long way to go.
Here's Catherine Russell,the executive director of
UNICEF to tell us more.
Catherine Russell (00:58):
In the last 50 years, the lives of
tens of millions of childrenhave been saved largely due to
one single reason, vaccines.
This year marks the 50thanniversary of the essential
programmeme on immunization, theway we organize and distribute
vaccines all around the world.
This immunization programmehas helped keep children
(01:19):
everywhere safe from manydiseases, including measles,
diphtheria, and polio.
The immunization programmeand the past 50 years have
shown the world what's humanlypossible when all of us,
scientists, health workers,teachers, parents, and the
international community cometogether for a common good.
The triumph of vaccines hasbeen a collective effort.
(01:42):
And collectively we canand must protect it.
Qali Id (01:49):
Vaccines are universally recognized as
among the safest, most costeffective and successful
public health interventionsto prevent fatalities and
enhance the quality of life.
So why did COVID 19vaccines feel like such a
hot, controversial topic?
In this episode, we'll bespeaking to three immunization
(02:09):
specialists who've workedacross the globe to ensure
people are able to access andreceive life saving vaccines,
the challenges they've faced,and the role SBC can play in
navigating those challenges.
First, let's go to FrancineGanter Restrepo, a social and
behaviour change specialistfor immunization and health
at the East and SouthernAfrica Regional Office at
(02:30):
UNICEF, to understand whatpeople's attitudes towards
vaccinations are now,after a global pandemic.
Francine Ganter (02:38):
I think that there's this assumption that
vaccine hesitancy is at large,particularly after COVID, we
hear a lot of stories abouthow people have lost confidence
in vaccines, but when weask people as individuals
what they want to do.
We actually see the opposite.
(03:01):
Over the last couple ofyears, we ran what we call a
community rapid assessment.
And what we found, actually,is that the vast majority
of people still want to getvaccines for their children.
And they believe thatvaccines are important.
And so that's not hesitancybecause hesitancy is defined
(03:21):
really as a motivational state,people who say they don't want
to get vaccines or they're notsure they want to get vaccines.
And it's usually tiedin with confidence.
So on both those indicators,confidence and motivation,
we're actually seeing verypositive results in our region.
In the countries where wesurveyed, always above 90
percent of people saying thatthey want vaccines and that they
(03:44):
think that they're important.
What we do see Instead,is this belief that other
people don't want vaccines.
In some countries, thatwas around 58 percent of
people thinking that theirclose friends and family
don't want them to getvaccines for their children.
Qali Id (04:05):
That's really interesting.
So people want vaccinesbut are afraid their
loved ones won't approve.
I can already see the rolesocial and behaviour change
can play here, drawing onsocial sciences to understand
and leverage these beliefs.
But is SBC widely acceptedin the immunization field?
(04:28):
We spoke to Heidi Larsonto see if she could give
us some perspective.
Heidi is an anthropologistand the author of stuck
how vaccine rumors startand why they don't go away,
which was released in 2020.
She founded the VaccineConfidence Project at the
London School of TropicalHygiene and Medicine and
before that worked at UNICEFas a senior advisor on the
(04:50):
introduction of new vaccines.
Heidi Larson (04:53):
I do think that in the last decade There has
been a shift in the immunizationcommunity, but public health
more broadly about theimportance of understanding
the social cultural contextand how much that matters
in people's decisions.
(05:14):
People often refer tobehavioural economics, but
we shouldn't be talkingabout behavioural economics.
We should be talkingabout behaviour and not
just behaviour because.
For instance, vaccinehesitancy is not a behaviour.
Vaccine confidenceis not a behaviour.
It's a psychological state.
Qali Id (05:33):
Was this something that was always clear to you?
The need to understandcontextual and psychological
factors in developingvaccine programmes?
Heidi Larson (05:41):
The turning point for me was when we faced
the northern Nigeria boycottof the polio vaccine and
cost the global eradicationprogramme hundreds of millions
of dollars to reset andit, you know, reinfected 20
countries previously polio free.
(06:03):
So to me, that was it.
That was a turning pointwhere I said, this is
not just a small deal.
This is costing millionsof dollars affecting
people's lives.
And the more we tried tounderstand what was going on,
it was a lot about distrust.
It was distrust about the West.
It was distrust aboutthe new government.
(06:24):
The Northern candidatehad lost to the South.
It was a lot of external things.
And frankly, none of themwere actual adverse events.
So something that happens aftervaccination that's perceived
to be caused by the vaccine.
There wasn't even thatin a lot of these cases.
It was political, it wasdistrust, it was anxiety,
(06:48):
so many things that I feltlike we needed to look at.
And frankly, in the 14 nowyears of the Vaccine Confidence
Project, we realized how much ofwhat we learned around vaccines
is very relevant to a numberof other health interventions.
And that's why my current workis moving much more to the
(07:09):
underlying issues of trust.
Qali Id (07:16):
Let's go back to Francine to hear
about her experienceand trust in her region.
Francine Ganter (07:21):
There's a lot of research that has
been conducted over the lastcouple of years that shows
the links between trust,trust in institutions, trust
in government, and our healthbehaviours, our vaccine
decisions in particular.
So in countries where we seelow trust in government, and
(07:42):
therefore low trust in theinstitutions that deliver
vaccine, we also see muchlower uptake of vaccines.
But it's not just trustin the vaccine itself.
It's trust in the, you know,the entire systems that
support delivery of vaccine.
I think what's interestingabout East and Southern Africa,
or perhaps even the entireof the African continent,
(08:05):
is the fact that the COVID19 vaccines in particular
came to, to these countries.
Quite a bit later, over a yearin some cases later than they
did in the West and that longdelay allowed for a lot of
rumors to build up a lot ofsuspicions around the vaccine.
(08:26):
I recall in 2022 whenI was in Cameroon.
and working with WHO todo some research around
the behavioural and socialdrivers of COVID 19 vaccines.
There were a lot of rumors goingaround about how the vaccines
in the West did indeed preventpeople from getting very sick.
(08:47):
but those that had cometo Cameroon were not
real COVID 19 vaccines.
You know, the, the rumors werearound that these vaccines
have been sent here tomake the African population
infertile or to exterminatethe African population.
And so of course, a lot ofthose rumors are tied in
with the colonial historiesin these countries.
(09:08):
And, you know, rightfully soa lack of trust in Western
institutions and a lack of trustin leadership that is seen to
be, you know, working togetherwith Western institutions to
the detriment of African people.
So that was quite challenging.
But what we noted in Cameroon,when we started inserted efforts
(09:28):
around COVID 19 vaccinationcampaigns was that if people
were being offered the vaccineIn a convenient way, and by
people who they trusted, theywould actually accept a COVID
19 vaccine, despite all therumors that they'd heard.
As part of the research I wasdoing in Cameroon, we learned
(09:50):
that the COVID 19 vaccineshad been made available
in major hospitals in thecities, but they were not
available, let's say, at thelocal health facilities where
people had, let's say, themidwife that they trusted that
delivered their child, right?
Or the local doctors that theywent to when they had a problem.
(10:11):
People said that they didn'tknow those doctors and
didn't trust those doctorsin the big hospitals.
And at the same time, some oftheir local clinics were equally
suspicious of COVID 19 vaccines.
So it became very clear forus that we needed to work much
more closely with the smallerclinics in the peripheries
(10:33):
and not just the big hospitalsand really make sure that the
health workers in those areaswere well equipped to talk
about COVID 19 vaccinationwith people who were coming in
and had questions about that.
And particularly, we neededto facilitate access to
the vaccine because theywere not willing to spend
time or money on transport.
(10:54):
to travel into the city center,you know, from wherever they
were living in the suburbs orrural areas outside to go get
a vaccine that they were notyet convinced that they needed,
that was actually going to bebeneficial to their health.
And we saw the same in manycountries across Africa.
Qali Id (11:18):
Histories of colonialism, mistrust in
governments and institutionsdelivering the vaccine.
It makes sense whymisinformation can really take
hold in these environments.
To understand misinformationa bit more, let's go to Dr.
Saad Omer.
An epidemiologist andthe founding dean of
the Peter O'Donnell, Jr.
(11:39):
School of Public Healthat UT Southwestern Medical
Center in Dallas, Texas, andpreviously headed the Yale
Institute for Global Health.
Dr. Saad Omer (11:49):
So, in terms of misinformation
and disinformation.
Misinformation is informationthat is not correct.
In our case, health relatedinformation, but it could be
intentional or unintentional.
Misinformation traditionallyis unintentional,
incorrect information.
Disinformation, by definition,is someone intentionally
(12:12):
spreading a piece ofinformation that happens
to be incorrect, but theintent part differentiates
it from misinformation.
Sometimes we use misinformationas an overarching term,
and sometimes, you know, itstarts as disinformation, but
the second order spread ismisinformation, in the sense
that the person who receivedthe piece of disinformation,
when they pass on, theydon't know themselves
(12:35):
whether it's, uh, that itwas intentionally spread.
I wrote an op ed on the NewYork Times, and I think it
came out on January 23rd, 2020.
With one confirmed case of COVID19 in the United States, it had
just barely started spreading.
And so I warned ofmisinformation being part of
(12:57):
what we should expect to see.
So That wasn't surprisingbecause it was not my first
rodeo, not my first outbreak,not my first pandemic.
And there were seriouspeople, serious well-meaning
journalists, communicationspeople, who just assumed that
when the vaccine will come,people will roll up their
sleeves and go get vaccinated.
(13:19):
Again, those of us who had beenpart of these responses knew
that that was wishful thinking.
Qali Id (13:28):
In a climate of misinformation, it's
understandable thatpeople would not be lining
up to get vaccinated.
But even before COVID andthe misinformation, were
people accepting of vaccines?
Heidi Larson (13:41):
Pre COVID there was already plateauing
for really a decade andin some countries dropping
of vaccine acceptance.
I think some of it's access,but also there's been quite
a significant transitionin the vaccine landscape.
There's a lot morevaccines out there.
I think that we Kept addingmore and more vaccines without
(14:06):
a proportionate amount ofengagement, communication,
support around them.
I mean, there was a hugeinvestment around EPI,
the expanded programme ofimmunization, in the beginning,
in the engagement, in thecommunication, in the trust
building, to get those sixbasic vaccines from 20 percent
(14:29):
to 80 percent globally.
It was tremendous.
Qali Id (14:32):
Why do you think that there's been less investment
in engagement, communication,and trust building?
Heidi Larson (14:39):
It's a much more complex vaccine environment.
They're more expensive and havedifferent kind of storage and
so I think countries have beenstruggling with this or they'll
start one of the new vaccinesand then can't keep it up.
You know, we've kind oftaken the public's trust
for granted on vaccines.
Frankly, I think far too long.
Qali Id (15:04):
So far we've touched on a number of factors
that might cause a personto not get vaccinated.
You think your familymembers might disapprove.
You might not trustthe governments
delivering the vaccine.
What we've yet to touch on.
is when your health systemisn't adequately funded.
Let's go back to Francine.
Francine Ganter (15:24):
In some countries, we see the issue
is that people are beingcharged for vaccination
services that should be free.
Even though vaccines aresubsidized by the government
and the mother should be ableto come in or a father should
be able to come in and gettheir child vaccinated free of
cost, sometimes health workerswill charge a fee for that.
And it's often beenbecause health workers
(15:45):
haven't been paid.
And so they're trying totop up their salaries.
So they're not,they're not bad people.
They're just trying to survive.
Clinics tend to be understaffed,under resourced, and that
means that you're oftentalking about, one vaccinator,
one doctor, one nurse, onemidwife who's attending to
a whole cohort of people,an entire set of villages.
(16:07):
And that's really trickyto manage when you're
the only person in andyou, you don't have help.
It often means that we seeoutreach cancelled as well,
so where health workers shouldbe going out into the villages
to deliver vaccines to peoplewho are unable to come in.
where they're understaffed,they tend not to do that.
And so again, that resultsin missed opportunities
(16:29):
for, for vaccination.
Some of the other serviceexperience elements that we've
seen that tend to result inpeople not getting vaccinated
is the service that you getonce you're there, the treatment
you get from health workers.
Again, These are people, youknow, they have good intentions,
but they're understaffed,they're under resourced and
(16:52):
overwhelmed, so sometimesperhaps not as patient or
respectful as they could bewith clients who come in,
and this results in a lot offrustration for people perhaps
who've traveled a long wayto bring their child in for
vaccination, and they're, youknow, berated because they
forgot their vaccination card.
Or they're told that theycame in late, and they're
(17:13):
told off about that.
So they get frustrated, andthey might not come back.
And that's really important withroutine immunization, because
it's not a one off thing, right?
A parent will have to comein many times over to see
their child fully vaccinated.
So it's really importantthat we create positive
service experiences.
Qali Id (17:34):
What other elements of the service experience have you
come across in your work thatcan really impact a person's
decision to get vaccinated?
Francine Ganter (17:43):
There's a number of, you know, service
experience issues that, youknow, are leading up to the
point of vaccination that happenat the point of vaccination.
And then also, after thefact, after the service.
So, for example, we often seethat parents don't know when
to come back for vaccines.
It may be written on thevaccination card, but when
(18:05):
you're dealing with populationsthat have low literacy levels.
Or they might not speak thekind of official language of the
country, but they'll speak someof the tribal languages, it's a
challenge to communicate thosethings, and so that doesn't
always happen in the way thatwe'd ideally like to see it.
And that results in parentsnot coming back, or not
(18:26):
coming back on time.
for the next vaccine as well.
Qali Id (18:36):
So making sure clinics are well staffed and that
vaccination cards are easy tounderstand will help ensure
more people get vaccinatedand come back for more.
Let's go back to Saad whocan explain why these actions
are key to rebuilding trust.
Dr. Saad Omer (18:54):
Competence in public health response
is not talked aboutenough as an antidote to
mistrust in institutions.
We trust institutions We trust,let's say, a courier, you know,
FedEx or DHL, that picks upa package from Accra, Ghana,
and gets it to Addis Ababa, orDhaka, or Karachi, or Kathmandu,
(19:22):
or Kansas, because it delivers.
Delivers for this caseliterally delivers for us for
international organizations,for local governments, for
public health agencies torebuild trust is to deliver
for the people and the trustwill come, get the vaccines to
where people need them, provideservices, quality of services
(19:45):
in peripheral primary headhealthcare locations, making
sure that bed nets are there,that antenatal care is there.
Making sure that whenpeople come to healthcare
facilities, they're treatedwith respect and dignity.
These kinds of things builda healthy connection between
those who are mandated toserve the public and the
(20:08):
public who is supposed tobe served by these services.
Qali Id (20:14):
People trust institutions that do what
they say they will do.
That makes a lot of sense.
And while Heidi agrees, she alsothinks that the impact of COVID
should not be taken lightly.
Heidi Larson (20:26):
It's one, trust in the ability of an individual
or a institution or a governmentto deliver on what they say
they're going to deliver.
And the second is their motive.
Is their motive really in mybest interest or are they just
trying to make another dollar?
And I have to say, also comingout of COVID, we are not taking
(20:52):
seriously, I think, the levelof emotional fragility that we
have in the planet right now.
And that has huge implications.
for people's confidence insystems, their reactivity, you
know, how quickly they react.
Also, uh, we've had asignificant negative knock on
(21:16):
effect on vaccines in particularbecause people felt like they
were pushed to have vaccinesthey didn't really want and so
they got it because it helpedthem see their friends at a
restaurant or go to a cafe orgo to a sport event or something
but they resented it and saidthat's it for me on vaccines.
(21:37):
I did it because I had to.
And particularly, we seein our research in the
Vaccine Confidence Project,the 18 to 34 year olds.
And to me, that's a real worrybecause that's the emerging
generation of potential parents.
So, there's a lot of fragility,a lot of anxiety, and I think
that's another thing we have topay attention to is historically
(22:01):
with vaccines, we've been sohyper focused on getting the
jab, you know, counting thenumbers and not the context.
Qali Id (22:13):
And when we focus on trying to increase vaccine
uptake without consideringthe context, what people have
endured, how their trust hasbeen broken and how their
feelings have changed, wemight do more harm than good.
Here's Heidi again.
Heidi Larson (22:27):
I'm not a fan of, not the social behavioural
part, but the change part,because it presumes people
are doing something wrong.
One of the things that willreally not help the equity
agenda is the premise thatpeople are doing something
wrong and that, you know, we'rehere to change their minds.
In the case of zero dosechildren, children who
(22:48):
have yet to receive anyroutine immunization, how
can social and behaviourchange approaches help?
Now, sometimes they're zerodose because they haven't had
access to those vaccines, butin many cases, as you know,
there's also this dimension of,well, they did have access, but
they didn't trust it, or theyweren't sure they wanted it,
or they, you know, were upsetthat this is the only thing
(23:11):
you're coming to them for whenyou're not taking care of their
water, and you're not, you know.
We are one of many differenthealth interventions that are
knocking on people's doors,and sometimes, you know,
they've had enough duringthat week or day or month.
You know, it'slike, Oh, you too.
(23:32):
So I think the more we couldget on the side of particularly
the people that we're tryingto reach is super important
because when people thinkthat you actually care about
where they're coming from,that's already a trust builder.
Qali Id (23:55):
And here we are, back to trust again.
Heidi described a case wherepeople may not want to take
the vaccine because they don'tfeel cared for in other ways.
If you listened to our systemstrengthening episode, you might
remember the example in Basra,where the community refused to
resolve their water scarcityissue because they felt their
(24:16):
government was not supportingthem in so many other ways.
Let's go back to Francine.
Francine Ganter (24:22):
We really need to think about
the system as a whole.
And what are the ways in whichgovernments and immunization
partners really need to show upfor people in communities and
really demonstrate that we aredelivering results for better
health, for better prospects,better futures, so that we're
(24:43):
rebuilding that trust, right?
And not just, let's say,sending out messages about
how vaccines are safe, becausethat's not going to have the
impact we need it to have.
It's really about showing whatwe do beyond immunization.
Qali Id (25:00):
That's our show.
Thank you to Heidi, Saad andFrancine for sharing their
insights and perspectivesfrom working in immunization
across a variety of contexts.
You can learn more about themand access links to research
and other resources they'veshared in our show notes.
(25:20):
There you can find a link toUNICEF's first ever programme
guidance filled with alibrary of guides and tools
to help anyone understand andimplement SBC for Children.
If you prefer a page turner,then you might want to
check out UNICEF's latestissue of Change Magazine,
Why Don't You Just Behave?
The publication distills thepast, present, and future of
(25:41):
social and behaviour change forchildren at UNICEF and beyond.
It has case studies, articles,cartoons, and even a crossword
to help experts and non expertsunderstand the role of SBC in
the challenges that lie ahead.
You can find all thedetails in our show notes.
Thank you so much for listening.
What is one intervention that has saved
six lives every minute,8, 000 lives every day
over the last 50 years?
Any guesses?
It starts with an I, endswith an N, and I promise
it's not just a productof our imagination.
Welcome back to the ABCs of SBC.
(00:27):
In this episode, we'll bediscussing immunization.
We've come a very long waysince the first vaccine.
The smallpox vaccine,which was invented in 1796.
This was a major breakthrough,kickstarting the development of
numerous life saving vaccinesand ultimately led to the global
eradication of smallpox in 1980.
(00:48):
But we still havea long way to go.
Here's Catherine Russell,the executive director of
UNICEF to tell us more.
Catherine Russell (00:58):
In the last 50 years, the lives of
tens of millions of childrenhave been saved largely due to
one single reason, vaccines.
This year marks the 50thanniversary of the essential
programmeme on immunization, theway we organize and distribute
vaccines all around the world.
This immunization programmehas helped keep children
(01:19):
everywhere safe from manydiseases, including measles,
diphtheria, and polio.
The immunization programmeand the past 50 years have
shown the world what's humanlypossible when all of us,
scientists, health workers,teachers, parents, and the
international community cometogether for a common good.
The triumph of vaccines hasbeen a collective effort.
(01:42):
And collectively we canand must protect it.
Qali Id (01:49):
Vaccines are universally recognized as
among the safest, most costeffective and successful
public health interventionsto prevent fatalities and
enhance the quality of life.
So why did COVID 19vaccines feel like such a
hot, controversial topic?
In this episode, we'll bespeaking to three immunization
(02:09):
specialists who've workedacross the globe to ensure
people are able to access andreceive life saving vaccines,
the challenges they've faced,and the role SBC can play in
navigating those challenges.
First, let's go to FrancineGanter Restrepo, a social and
behaviour change specialistfor immunization and health
at the East and SouthernAfrica Regional Office at
(02:30):
UNICEF, to understand whatpeople's attitudes towards
vaccinations are now,after a global pandemic.
Francine Ganter (02:38):
I think that there's this assumption that
vaccine hesitancy is at large,particularly after COVID, we
hear a lot of stories abouthow people have lost confidence
in vaccines, but when weask people as individuals
what they want to do.
We actually see the opposite.
(03:01):
Over the last couple ofyears, we ran what we call a
community rapid assessment.
And what we found, actually,is that the vast majority
of people still want to getvaccines for their children.
And they believe thatvaccines are important.
And so that's not hesitancybecause hesitancy is defined
(03:21):
really as a motivational state,people who say they don't want
to get vaccines or they're notsure they want to get vaccines.
And it's usually tiedin with confidence.
So on both those indicators,confidence and motivation,
we're actually seeing verypositive results in our region.
In the countries where wesurveyed, always above 90
percent of people saying thatthey want vaccines and that they
(03:44):
think that they're important.
What we do see Instead,is this belief that other
people don't want vaccines.
In some countries, thatwas around 58 percent of
people thinking that theirclose friends and family
don't want them to getvaccines for their children.
Qali Id (04:05):
That's really interesting.
So people want vaccinesbut are afraid their
loved ones won't approve.
I can already see the rolesocial and behaviour change
can play here, drawing onsocial sciences to understand
and leverage these beliefs.
But is SBC widely acceptedin the immunization field?
(04:28):
We spoke to Heidi Larsonto see if she could give
us some perspective.
Heidi is an anthropologistand the author of stuck
how vaccine rumors startand why they don't go away,
which was released in 2020.
She founded the VaccineConfidence Project at the
London School of TropicalHygiene and Medicine and
before that worked at UNICEFas a senior advisor on the
(04:50):
introduction of new vaccines.
Heidi Larson (04:53):
I do think that in the last decade There has
been a shift in the immunizationcommunity, but public health
more broadly about theimportance of understanding
the social cultural contextand how much that matters
in people's decisions.
(05:14):
People often refer tobehavioural economics, but
we shouldn't be talkingabout behavioural economics.
We should be talkingabout behaviour and not
just behaviour because.
For instance, vaccinehesitancy is not a behaviour.
Vaccine confidenceis not a behaviour.
It's a psychological state.
Qali Id (05:33):
Was this something that was always clear to you?
The need to understandcontextual and psychological
factors in developingvaccine programmes?
Heidi Larson (05:41):
The turning point for me was when we faced
the northern Nigeria boycottof the polio vaccine and
cost the global eradicationprogramme hundreds of millions
of dollars to reset andit, you know, reinfected 20
countries previously polio free.
(06:03):
So to me, that was it.
That was a turning pointwhere I said, this is
not just a small deal.
This is costing millionsof dollars affecting
people's lives.
And the more we tried tounderstand what was going on,
it was a lot about distrust.
It was distrust about the West.
It was distrust aboutthe new government.
(06:24):
The Northern candidatehad lost to the South.
It was a lot of external things.
And frankly, none of themwere actual adverse events.
So something that happens aftervaccination that's perceived
to be caused by the vaccine.
There wasn't even thatin a lot of these cases.
It was political, it wasdistrust, it was anxiety,
(06:48):
so many things that I feltlike we needed to look at.
And frankly, in the 14 nowyears of the Vaccine Confidence
Project, we realized how much ofwhat we learned around vaccines
is very relevant to a numberof other health interventions.
And that's why my current workis moving much more to the
(07:09):
underlying issues of trust.
Qali Id (07:16):
Let's go back to Francine to hear
about her experienceand trust in her region.
Francine Ganter (07:21):
There's a lot of research that has
been conducted over the lastcouple of years that shows
the links between trust,trust in institutions, trust
in government, and our healthbehaviours, our vaccine
decisions in particular.
So in countries where we seelow trust in government, and
(07:42):
therefore low trust in theinstitutions that deliver
vaccine, we also see muchlower uptake of vaccines.
But it's not just trustin the vaccine itself.
It's trust in the, you know,the entire systems that
support delivery of vaccine.
I think what's interestingabout East and Southern Africa,
or perhaps even the entireof the African continent,
(08:05):
is the fact that the COVID19 vaccines in particular
came to, to these countries.
Quite a bit later, over a yearin some cases later than they
did in the West and that longdelay allowed for a lot of
rumors to build up a lot ofsuspicions around the vaccine.
(08:26):
I recall in 2022 whenI was in Cameroon.
and working with WHO todo some research around
the behavioural and socialdrivers of COVID 19 vaccines.
There were a lot of rumors goingaround about how the vaccines
in the West did indeed preventpeople from getting very sick.
(08:47):
but those that had cometo Cameroon were not
real COVID 19 vaccines.
You know, the, the rumors werearound that these vaccines
have been sent here tomake the African population
infertile or to exterminatethe African population.
And so of course, a lot ofthose rumors are tied in
with the colonial historiesin these countries.
(09:08):
And, you know, rightfully soa lack of trust in Western
institutions and a lack of trustin leadership that is seen to
be, you know, working togetherwith Western institutions to
the detriment of African people.
So that was quite challenging.
But what we noted in Cameroon,when we started inserted efforts
(09:28):
around COVID 19 vaccinationcampaigns was that if people
were being offered the vaccineIn a convenient way, and by
people who they trusted, theywould actually accept a COVID
19 vaccine, despite all therumors that they'd heard.
As part of the research I wasdoing in Cameroon, we learned
(09:50):
that the COVID 19 vaccineshad been made available
in major hospitals in thecities, but they were not
available, let's say, at thelocal health facilities where
people had, let's say, themidwife that they trusted that
delivered their child, right?
Or the local doctors that theywent to when they had a problem.
(10:11):
People said that they didn'tknow those doctors and
didn't trust those doctorsin the big hospitals.
And at the same time, some oftheir local clinics were equally
suspicious of COVID 19 vaccines.
So it became very clear forus that we needed to work much
more closely with the smallerclinics in the peripheries
(10:33):
and not just the big hospitalsand really make sure that the
health workers in those areaswere well equipped to talk
about COVID 19 vaccinationwith people who were coming in
and had questions about that.
And particularly, we neededto facilitate access to
the vaccine because theywere not willing to spend
time or money on transport.
(10:54):
to travel into the city center,you know, from wherever they
were living in the suburbs orrural areas outside to go get
a vaccine that they were notyet convinced that they needed,
that was actually going to bebeneficial to their health.
And we saw the same in manycountries across Africa.
Qali Id (11:18):
Histories of colonialism, mistrust in
governments and institutionsdelivering the vaccine.
It makes sense whymisinformation can really take
hold in these environments.
To understand misinformationa bit more, let's go to Dr.
Saad Omer.
An epidemiologist andthe founding dean of
the Peter O'Donnell, Jr.
(11:39):
School of Public Healthat UT Southwestern Medical
Center in Dallas, Texas, andpreviously headed the Yale
Institute for Global Health.
Dr. Saad Omer (11:49):
So, in terms of misinformation
and disinformation.
Misinformation is informationthat is not correct.
In our case, health relatedinformation, but it could be
intentional or unintentional.
Misinformation traditionallyis unintentional,
incorrect information.
Disinformation, by definition,is someone intentionally
(12:12):
spreading a piece ofinformation that happens
to be incorrect, but theintent part differentiates
it from misinformation.
Sometimes we use misinformationas an overarching term,
and sometimes, you know, itstarts as disinformation, but
the second order spread ismisinformation, in the sense
that the person who receivedthe piece of disinformation,
when they pass on, theydon't know themselves
(12:35):
whether it's, uh, that itwas intentionally spread.
I wrote an op ed on the NewYork Times, and I think it
came out on January 23rd, 2020.
With one confirmed case of COVID19 in the United States, it had
just barely started spreading.
And so I warned ofmisinformation being part of
(12:57):
what we should expect to see.
So That wasn't surprisingbecause it was not my first
rodeo, not my first outbreak,not my first pandemic.
And there were seriouspeople, serious well-meaning
journalists, communicationspeople, who just assumed that
when the vaccine will come,people will roll up their
sleeves and go get vaccinated.
(13:19):
Again, those of us who had beenpart of these responses knew
that that was wishful thinking.
Qali Id (13:28):
In a climate of misinformation, it's
understandable thatpeople would not be lining
up to get vaccinated.
But even before COVID andthe misinformation, were
people accepting of vaccines?
Heidi Larson (13:41):
Pre COVID there was already plateauing
for really a decade andin some countries dropping
of vaccine acceptance.
I think some of it's access,but also there's been quite
a significant transitionin the vaccine landscape.
There's a lot morevaccines out there.
I think that we Kept addingmore and more vaccines without
(14:06):
a proportionate amount ofengagement, communication,
support around them.
I mean, there was a hugeinvestment around EPI,
the expanded programme ofimmunization, in the beginning,
in the engagement, in thecommunication, in the trust
building, to get those sixbasic vaccines from 20 percent
(14:29):
to 80 percent globally.
It was tremendous.
Qali Id (14:32):
Why do you think that there's been less investment
in engagement, communication,and trust building?
Heidi Larson (14:39):
It's a much more complex vaccine environment.
They're more expensive and havedifferent kind of storage and
so I think countries have beenstruggling with this or they'll
start one of the new vaccinesand then can't keep it up.
You know, we've kind oftaken the public's trust
for granted on vaccines.
Frankly, I think far too long.
Qali Id (15:04):
So far we've touched on a number of factors
that might cause a personto not get vaccinated.
You think your familymembers might disapprove.
You might not trustthe governments
delivering the vaccine.
What we've yet to touch on.
is when your health systemisn't adequately funded.
Let's go back to Francine.
Francine Ganter (15:24):
In some countries, we see the issue
is that people are beingcharged for vaccination
services that should be free.
Even though vaccines aresubsidized by the government
and the mother should be ableto come in or a father should
be able to come in and gettheir child vaccinated free of
cost, sometimes health workerswill charge a fee for that.
And it's often beenbecause health workers
(15:45):
haven't been paid.
And so they're trying totop up their salaries.
So they're not,they're not bad people.
They're just trying to survive.
Clinics tend to be understaffed,under resourced, and that
means that you're oftentalking about, one vaccinator,
one doctor, one nurse, onemidwife who's attending to
a whole cohort of people,an entire set of villages.
(16:07):
And that's really trickyto manage when you're
the only person in andyou, you don't have help.
It often means that we seeoutreach cancelled as well,
so where health workers shouldbe going out into the villages
to deliver vaccines to peoplewho are unable to come in.
where they're understaffed,they tend not to do that.
And so again, that resultsin missed opportunities
(16:29):
for, for vaccination.
Some of the other serviceexperience elements that we've
seen that tend to result inpeople not getting vaccinated
is the service that you getonce you're there, the treatment
you get from health workers.
Again, These are people, youknow, they have good intentions,
but they're understaffed,they're under resourced and
(16:52):
overwhelmed, so sometimesperhaps not as patient or
respectful as they could bewith clients who come in,
and this results in a lot offrustration for people perhaps
who've traveled a long wayto bring their child in for
vaccination, and they're, youknow, berated because they
forgot their vaccination card.
Or they're told that theycame in late, and they're
(17:13):
told off about that.
So they get frustrated, andthey might not come back.
And that's really important withroutine immunization, because
it's not a one off thing, right?
A parent will have to comein many times over to see
their child fully vaccinated.
So it's really importantthat we create positive
service experiences.
Qali Id (17:34):
What other elements of the service experience have you
come across in your work thatcan really impact a person's
decision to get vaccinated?
Francine Ganter (17:43):
There's a number of, you know, service
experience issues that, youknow, are leading up to the
point of vaccination that happenat the point of vaccination.
And then also, after thefact, after the service.
So, for example, we often seethat parents don't know when
to come back for vaccines.
It may be written on thevaccination card, but when
(18:05):
you're dealing with populationsthat have low literacy levels.
Or they might not speak thekind of official language of the
country, but they'll speak someof the tribal languages, it's a
challenge to communicate thosethings, and so that doesn't
always happen in the way thatwe'd ideally like to see it.
And that results in parentsnot coming back, or not
(18:26):
coming back on time.
for the next vaccine as well.
Qali Id (18:36):
So making sure clinics are well staffed and that
vaccination cards are easy tounderstand will help ensure
more people get vaccinatedand come back for more.
Let's go back to Saad whocan explain why these actions
are key to rebuilding trust.
Dr. Saad Omer (18:54):
Competence in public health response
is not talked aboutenough as an antidote to
mistrust in institutions.
We trust institutions We trust,let's say, a courier, you know,
FedEx or DHL, that picks upa package from Accra, Ghana,
and gets it to Addis Ababa, orDhaka, or Karachi, or Kathmandu,
(19:22):
or Kansas, because it delivers.
Delivers for this caseliterally delivers for us for
international organizations,for local governments, for
public health agencies torebuild trust is to deliver
for the people and the trustwill come, get the vaccines to
where people need them, provideservices, quality of services
(19:45):
in peripheral primary headhealthcare locations, making
sure that bed nets are there,that antenatal care is there.
Making sure that whenpeople come to healthcare
facilities, they're treatedwith respect and dignity.
These kinds of things builda healthy connection between
those who are mandated toserve the public and the
(20:08):
public who is supposed tobe served by these services.
Qali Id (20:14):
People trust institutions that do what
they say they will do.
That makes a lot of sense.
And while Heidi agrees, she alsothinks that the impact of COVID
should not be taken lightly.
Heidi Larson (20:26):
It's one, trust in the ability of an individual
or a institution or a governmentto deliver on what they say
they're going to deliver.
And the second is their motive.
Is their motive really in mybest interest or are they just
trying to make another dollar?
And I have to say, also comingout of COVID, we are not taking
(20:52):
seriously, I think, the levelof emotional fragility that we
have in the planet right now.
And that has huge implications.
for people's confidence insystems, their reactivity, you
know, how quickly they react.
Also, uh, we've had asignificant negative knock on
(21:16):
effect on vaccines in particularbecause people felt like they
were pushed to have vaccinesthey didn't really want and so
they got it because it helpedthem see their friends at a
restaurant or go to a cafe orgo to a sport event or something
but they resented it and saidthat's it for me on vaccines.
(21:37):
I did it because I had to.
And particularly, we seein our research in the
Vaccine Confidence Project,the 18 to 34 year olds.
And to me, that's a real worrybecause that's the emerging
generation of potential parents.
So, there's a lot of fragility,a lot of anxiety, and I think
that's another thing we have topay attention to is historically
(22:01):
with vaccines, we've been sohyper focused on getting the
jab, you know, counting thenumbers and not the context.
Qali Id (22:13):
And when we focus on trying to increase vaccine
uptake without consideringthe context, what people have
endured, how their trust hasbeen broken and how their
feelings have changed, wemight do more harm than good.
Here's Heidi again.
Heidi Larson (22:27):
I'm not a fan of, not the social behavioural
part, but the change part,because it presumes people
are doing something wrong.
One of the things that willreally not help the equity
agenda is the premise thatpeople are doing something
wrong and that, you know, we'rehere to change their minds.
In the case of zero dosechildren, children who
(22:48):
have yet to receive anyroutine immunization, how
can social and behaviourchange approaches help?
Now, sometimes they're zerodose because they haven't had
access to those vaccines, butin many cases, as you know,
there's also this dimension of,well, they did have access, but
they didn't trust it, or theyweren't sure they wanted it,
or they, you know, were upsetthat this is the only thing
(23:11):
you're coming to them for whenyou're not taking care of their
water, and you're not, you know.
We are one of many differenthealth interventions that are
knocking on people's doors,and sometimes, you know,
they've had enough duringthat week or day or month.
You know, it'slike, Oh, you too.
(23:32):
So I think the more we couldget on the side of particularly
the people that we're tryingto reach is super important
because when people thinkthat you actually care about
where they're coming from,that's already a trust builder.
Qali Id (23:55):
And here we are, back to trust again.
Heidi described a case wherepeople may not want to take
the vaccine because they don'tfeel cared for in other ways.
If you listened to our systemstrengthening episode, you might
remember the example in Basra,where the community refused to
resolve their water scarcityissue because they felt their
(24:16):
government was not supportingthem in so many other ways.
Let's go back to Francine.
Francine Ganter (24:22):
We really need to think about
the system as a whole.
And what are the ways in whichgovernments and immunization
partners really need to show upfor people in communities and
really demonstrate that we aredelivering results for better
health, for better prospects,better futures, so that we're
(24:43):
rebuilding that trust, right?
And not just, let's say,sending out messages about
how vaccines are safe, becausethat's not going to have the
impact we need it to have.
It's really about showing whatwe do beyond immunization.
Qali Id (25:00):
That's our show.
Thank you to Heidi, Saad andFrancine for sharing their
insights and perspectivesfrom working in immunization
across a variety of contexts.
You can learn more about themand access links to research
and other resources they'veshared in our show notes.
(25:20):
There you can find a link toUNICEF's first ever programme
guidance filled with alibrary of guides and tools
to help anyone understand andimplement SBC for Children.
If you prefer a page turner,then you might want to
check out UNICEF's latestissue of Change Magazine,
Why Don't You Just Behave?
The publication distills thepast, present, and future of
(25:41):
social and behaviour change forchildren at UNICEF and beyond.
It has case studies, articles,cartoons, and even a crossword
to help experts and non expertsunderstand the role of SBC in
the challenges that lie ahead.
You can find all thedetails in our show notes.
Thank you so much for listening.
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